PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using Ammonia Perfusion PET
Phase: NA
Conditions: Liver Tumor, Liver Neoplasms
Sponsor: Dana-Farber Cancer Institute

 
 
 
 
PROTOCOL 13-464 
 
 
Title: FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results 
Using Perfusion PET 
 
 
 
Principal Investigator: 
Paul B. Shyn, M.D. (Abdominal Imaging and Interventional 
Radiologist) 
Brigham and Women’s Hospital 
 
 
NCT02018107 
 
Date Posted: 3/1/2019 

Date Posted: 3/1/2019 
 
ON HOLD 
 
STATUS PAGE 
 
PROTOCOL 13-464 
 
 
 
ALL RESEARCH ACTIVITIES MUST STOP 
DUE TO EXPIRED STUDY APPROVAL 
 
 
Research activities include, but are not limited to, recruitment and enrollment of 
subjects, collection of specimens, research on previously collected specimens, 
review of medical records or other health information, data analysis, and 
performance of research tests/procedures, treatment, or follow-up on previously 
enrolled subjects. 
 
• If you wish to reinstate IRB approval of your project, please submit a 
continuing review form immediately via OHRS submit.  If the continuing 
review form has been submitted and the continuing review is in process, 
you must await IRB approval before resuming any research activities.  
 
• If any research activities are necessary for subject safety and welfare, a 
Request to Continue Research Interventions may be submitted for IRB 
consideration.  This form can be found on the 
OHRS website and be submitted via OHRS submit.   
 
• If a request to continue research interventions has already been approved, 
please refer to that email notice for information about research that may 
continue during this lapse in IRB approval.  The study team is responsible 
for notifying the relevant departments of this approval.   
 
• If you do not wish to continue this project, you must submit a final report 
using the study completion form. 
 
Any questions regarding this hold should be directed to the study’s 
Principal Investigator. 
 

Status Page 
 
 
 
PROTOCOL 13-464 
 
 
 
 
 
  
Closed to New Accrual  
 
 
 
 
 
 
 
 
 
 
 
Closure Effective Date: 03/09/2018 
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 
 
 
 
 

 
 
 
 
 
 
 
Office for Human Research Studies 
 
DANA-FARBER / HARVARD CANCER CENTER 
Version: 4.22.16a 
 
 
Protocol Front Sheet 
DFCI Protocol No.: 13-464  
 
1.  PROTOCOL INFORMATION 
 
Title: PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using Perfusion PET 
Phase: [pull down] 
Sponsor Study Number:       
 
2.  DF/HCC STUDY CONTACT INFORMATION 
 
Primary Study Contact: Paul B. Shyn, M.D.  
Email:  pshyn@partners.org 
Phone:  617-732-6304 
 
INVESTIGATORS:  (List only those under DFCI IRB, i.e., from institutions listed in Section 6 below) 
Overall PI: 
Paul B. Shyn, M.D. 
Phone: 617-732-6304 
Institution(s): 
BWH 
Site Responsible PI: 
Paul B. Shyn, M.D. 
Phone: 617-732-6304 
Institution(s): 
BWH 
 
 
3.  DRUG / DEVICE INFORMATION    N/A: 
  
 
 Drug(s), Biologic(s):  N13-ammonia, Arm #1; (Arm #2: F18-
fluorodeoxyglucose, FDA approved for indication - no IND or IND 
exemption required) 
 Device(s) Name:        
Provided by: BICOR BWH 
IND Exempt: 
        ‐or‐ 
IND#:            Holder Type: [pull down]    
IND Holder Name:        
Provided by:      
IDE Exempt: 
        ‐or‐ 
IDE #:            Holder Type: [pull down]    
IDE Holder Name:        
 
4.  PROTOCOL COORDINATION, FUNDING, MODE 
 
Regulatory Sponsor: 
Funding/Support (check all that apply): 
Primary Disease Group:  Cancer Imaging 
DF/HCC Investigator  Cancer Imaging 
 Industry: Siemens 
 
 
 Federal Organization:       
 
CTEP Study: No 
      Grant #:       
 
 
 Internal Funding:       
 
 
 Non-Federal:       
 
 Other:       
 
Protocol Involves (check all that apply as listed in the protocol document, even if not part of the research but is mandated by the protocol document): 
 Chemotherapy 
 Hormone Therapy 
 Medical Record Review 
 Immunotherapy 
 Vaccine 
 Questionnaires/Surveys/Interviews 
 Surgery 
 Data Repository 
 Radiological Exams 
 Bone Marrow/Stem Cell Transplant 
 Exercise/Physical Therapy 
 Required Biopsy Study 
 Cell Based Therapy 
 Genetic Studies 
 Human Embryonic Stem Cell 
 Gene Transfer (use of recombinant DNA) 
 Human Material Banking 
 Quality of Life 
 Radiation Therapy 
 Human Material Collection 
 Other: Radiotracer administration for PET scans 
during routine Interventional Radiology Tumor 
Ablation procedure 
 
5.  SUBJECT POPULATION (also applies to medical record review and specimen collection studies) 
 
Total Study-Wide Enrollment Goal: 75 
Greater than 25% of the overall study accrual will be at DF/HCC: 
 Yes   
 No 
Total DF/HCC Estimated Enrollment Goal: 75 
Adult Age Range: 18+ 
Pediatric Age Range: N/A 
Will all subjects be recruited from pediatric clinics?    
 Yes    
 No 
If enrolling both adults and pediatric subjects, anticipated percent of pediatric subjects: N/A 
Retrospective Medical Record Reviews only (Please provide date range): from       to       
 
6.  DF/HCC PARTICIPANTS UNDER DFCI IRB (check all that apply) 
 
 Beth Israel Deaconess Medical Center (BIDMC) 
 Beth Israel Deaconess Medical Center – Needham (BIDMC-Needham) 
 Boston Children’s Hospital (BCH) 
 Dana-Farber/New Hampshire Oncology-Hematology (DFCI @ NHOH) 
 Brigham and Women’s Hospital (BWH) 
 Dana-Farber at Steward St. Elizabeth’s Medical Center (DFCI @ SEMC) 
 Dana-Farber Cancer Institute (DFCI) 
 Dana-Farber at Milford Regional Cancer Center (DFCI @ MRCC) 
 Massachusetts General Hospital (MGH) 
 Mass General/North Shore Cancer Center (MGH @ NSCC) 
 
 Mass General at Emerson Hospital – Bethke (MGH @ EH) 
 
 DF/BWCC in Clinical Affiliation with South Shore Hospital (DFCI @ SSH) 
 
 
7.  NON-DF/HCC PARTICIPANTS UNDER DFCI IRB (check all that apply) 
 
 
Cape Cod Healthcare (CCH)  
 
Lowell General Hospital (LGH)  
 
New Hampshire Oncology-Hematology-P.A. (NHOH)  
 
Newton-Wellesley Hospital (NWH) 
 Dana-Farber/Faulkner Hospital (FH) 
 New England Cancer Specialists (NECS)  
 Broad Institute 
 

Protocol Front Sheet 
 
FS Page: 2 
 
8.  DF/HCC INITIATED STUDIES ONLY  - INSTITUTIONAL PARTICIPANTS UNDER OTHER IRB  (N/A: 
) 
 
 
DF/HCC Multi-Center Protocols:  (list institution/location) 
 
DF/PCC Network Affiliates: (list institution/location) 
      
      
     
      
 

 
Log Sheet 
Page 1 of 1 
 
Protocol Number: 13-464 
 
Approval Date:  
11/26/13 
(IRB meeting date when protocol/consent  
 approved or conditionally approved) 
 
Activation Date:  
01/22/14 
(Date when protocol open to patient entry) 
 
Approval signatures are on file in the Office for Human Research Studies, tel. 617-632-3029. 
 
 
 
 
 
 
 
 
 
            
Date 
Posted 
Revised Sections 
IRB 
Approval 
Date 
OHRS 
Version Date 
02/04/14 
Consent Form replaced due to Amendment #1 
02/03/14 
02/04/14 
02/25/14 
Correction: Consent Form replaced due to incorrect version 
previously provided (missing signature box)  
02/03/14 
02/04/14 
06/17/14 
Protocol replaced due to Amendment #2 
06/11/14 
N/A 
11/26/14 
ON HOLD:  All research must stop due to lapsed Continuing 
Review.  Study expired 11/26/14 
N/A 
N/A 
04/27/15 
Protocol, Consent Form and Front Sheet replaced due to 
Amendment #3 
03/31/15 
04/27/15 
04/27/15 
On HOLD removed; Study renewal/ Consent Form footer 
replaced due to Continuing Review #1 
04/02/15 
N/A 
04/28/15 
Temporary closed to new accrual: administrative hold by 
DMSC as of 4/28/2015.  Questions regarding the temporary 
hold can be directed to the DSMC (via Nareg Grigorian in 
QACT) 
n/a 
n/a 
05/29/15 
Re-open to accrual – due to Amendment #4 
05/18/15 
N/A 
06/18/15 
Temporary closed to new accrual: administrative hold per 
the IRB on 06/04/15 (OE #4). 
n/a 
n/a 
Date 
Posted 
Revised Sections 
IRB Approval 
Date 
OnCore 
Version Date 
09/29/15 
Study Re-Opened due to Amendment #5 
08/28/15 
N/A 
11/17/15 
Consent Form replaced due to Amendment #6 
11/09/15 
11/13/15 
03/24/16 
Consent Form replaced due to Amendment #7 
02/29/16 
03/07/16 
03/31/16 
Study renewal / Consent Form footer replaced due to 
Continuing Review #2 
03/24/16 
03/31/16 
Date 
Posted 
Revised Sections 
Approved 
Date 
Version Date 
(OnCore) 
12/12/16 
Arm 2 of study opened; Arm 1 now closed to accrual: 
Protocol, Eligibility Checklist and Front Sheet replaced; Arm 
2 Consent Form added due to Amendment #8 
10/04/16 
12/12/16 
Date 
Posted 
Revised Sections 
Approved 
Date 
Version Date 
(OnCore) 
03/22/2017 
Study renewal/ Consent Form footers replaced due to 
Continuing Review #3 
03/16/2017 
03/22/2017 
03/15/2018 
Study renewal/Consent Form footers replaced per 
Continuing Review #4 
03/01/2018 
03/15/2018 
03/26/2018 
Permanent Closure to New Accrual:  due to Funding 
(effective date:  03/09/2018; Amendment #9) 
n/a 
n/a 
03/01/2019 
ON HOLD: All research must stop due to lapsed Continuing 
Review. Study approval expired 13-464   
N/A 
N/A 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
DF/HCC Biomedical Protocol Template for Investigator‐Written Protocols 
Version 10/13/2010 
 

 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
ProtocolVersion Date:  Version 4; 9/6/2016 
 
NCI Protocol#: N/A 
 
Local Protocol #: 
 
 
Title: FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results 
Using Perfusion PET 
 
Principal Investigator: 
 
Paul B. Shyn, M.D. (Abdominal Imaging and Interventional 
Radiologist) 
Brigham and Women’s Hospital 
 
Coordinating Center: N/A 
 
Co‐Investigators:  
 
Kemal Tuncali, M.D. (Abdominal Imaging and Interventional Radiologist) 
Victor H Gerbaudo, PhD, MSHCA: (Clinical Nuclear Oncology Scientist, Associate Scientific 
Director, AMIGO) 
Stuart G. Silverman, M.D. (Abdominal Imaging and Interventional Radiologist) 
Vincent Levesque, M.S. (Medical Physicist) 
Tina Kapur, PhD (Executive Director, AMIGO) 
 
All investigators: Brigham and Women’s Hospital 
 
Statistician: Paul J. Catalano, ScD (DFCI) 
 
Study Coordinator: Danielle Chamberlain 
 
Responsible Research Nurse: N/A 
 
Responsible Data Manager: Paul B. Shyn, M.D. 
 
Agent(s): Arm 1: N13-Ammonia (IND # 119482, exempt, 8/27/13) , BWH cyclotron (BICOR) 
 
 
 
Arm 2: F18-fluorodeoxyglucose (FDG), BWH cyclotron (BICOR) 
 
 
 

 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Perfusion PET 
 
 
6/9/2014  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
SCHEMA 
 
 Perfusion PET Assessment of Liver Tumor Ablations 
 
(Gray diamonds contain research activities; Arm 1 is as shown; Arm 2 substitutes FDG for Ammonia and only uses 
pathway 1) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further ablations needed or 
performed based on routine CT  
Additional overlapping 
ablation needed based 
on  routine CT. Repeat 
ablation performed per 
standard clinical 
practice 
Stop: routine 
post-procedure 
care and follow-
up imaging, 
including 24-
hour MRI (or 
CT if MRI not 
possible) 
FDG PET/CTguided liver tumor ablation 
performed with or without overlapping ablation 
treatments as planned preprocedurally using 
standard of care techniques 
Ammonia (arm 1) or 
FDG (arm 2) 
perfusion PET (#1) for 
intraprocedural 
monitoring of initial 
ablation results 
IV contrast enhanced CT obtained 
intraprocedurally to monitor ablation results per 
standard clinical practice. IV contrast limited to 
patients with adequate renal function (EGFR > 
30) and no contrast media allergy. Alternatively, 
CT without contrast. 
Ammonia (arm 1 
only) perfusion PET 
(#2) for 
intraprocedural 
monitoring of 
additional overlapping 
ablation results  
Pathway 
1 
Pathway 
2 
Arm 1 
only  

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
 
Perfusion PET Assessment of Liver Tumor Ablations 
Protocol Version Date 9/6/2016 
 
TABLE OF CONTENTS 
1. 
OBJECTIVES .................................................................................................................................................... 1 
1.1 
 Study Design - Abstract ............................................................................................................................. 1 
1.2 
Primary Objectives ..................................................................................................................................... 5 
1.3 
Secondary Objectives ................................................................................................................................. 6 
2. 
BACKGROUND ................................................................................................................................................ 6 
2.1 
Study Agent(s) ............................................................................................................................................. 6 
2.2 
Study Disease.............................................................................................................................................. 6 
2.3 
Rationale and Correlative Studies Background ......................................................................................... 6 
3. 
PARTICIPANT SELECTION ........................................................................................................................ 10 
3.1 
Eligibility Criteria .................................................................................................................................... 10 
3.2 
Exclusion Criteria .................................................................................................................................. 11 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ................................................. 11 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 13 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ..................................................................... 13 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ................................................................. 13 
4.3 
General Guidelines for Other Participating Institutions - N/A ......................................................... 14 
4.4 
Registration Process for Other Participating Institutions - N/A ............................................................. 14 
5. 
TREATMENT PLAN- N/A ............................................................................................................................. 14 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS – N/A ......................... 14 
7. 
DRUG FORMULATION AND ADMINISTRATION – N/A ....................................................................... 15 
8. 
CORRELATIVE/SPECIAL STUDIES – N/A ............................................................................................... 19 
9. 
STUDY CALENDAR ...................................................................................................................................... 19 
10. 
MEASUREMENT OF EFFECT..................................................................................................................... 20 
11. 
ADVERSE EVENT REPORTING REQUIREMENTS .......................................................................... 21 
11.1 
Definitions ................................................................................................................................................ 21 
11.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 22 
11.3 
Reporting Requirements ........................................................................................................................... 23 
11.4 
Reporting to the Study Sponsor ................................................................................................................ 23 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
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11.5 
Reporting to the Institutional Review Board (IRB) ................................................................................... 24 
11.6 
Reporting to the Food and Drug Administration (FDA) .......................................................................... 25 
11.7 
Reporting to the NIH Office of Biotechnology Activities (OBA)............................................................... 25 
11.8 
Reporting to the Institutional Biosafety Committee (IBC) ........................................................................ 25 
11.9 
Reporting to Hospital Risk Management .................................................................................................. 25 
11.10 
Monitoring of Adverse Events and Period of Observation ....................................................................... 25 
12. 
DATA AND SAFETY MONITORING ..................................................................................................... 26 
12.1 
Data Reporting ......................................................................................................................................... 27 
12.2 
Safety Meetings ......................................................................................................................................... 27 
12.3 
Monitoring ................................................................................................................................................ 27 
13. 
REGULATORY CONSIDERATIONS ..................................................................................................... 27 
13.1 
Protocol Review and Amendments ........................................................................................................... 28 
13.2 
Informed Consent ..................................................................................................................................... 28 
13.3 
Ethics and Good Clinical Practice (GCP) ............................................................................................... 28 
13.4 
Study Documentation ................................................................................................................................ 29 
13.5 
Records Retention ..................................................................................................................................... 29 
13.6 
Multi-center Guidelines – N/A .................................................................................................................. 30 
13.7 
Cooperative Research and Development Agreement (CRADA)/Clinical Trials Agreement (CTA) – N/A 30 
14. 
STATISTICAL CONSIDERATIONS ....................................................................................................... 31 
14.1 
Study Design/Endpoints ............................................................................................................................ 31 
14.2 
Sample Size/Accrual Rate ......................................................................................................................... 34 
14.3 
Stratification Factors – N/A ..................................................................................................................... 34 
14.4 
Analysis of Secondary Endpoints .............................................................................................................. 34 
14.5 
Reporting and Exclusions ......................................................................................................................... 34 
15. 
PUBLICATION PLAN ............................................................................................................................... 34 
16. 
REFERENCES ............................................................................................................................................ 35 
17. 
APPENDICES ............................................................................................................................................. 35 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Perfusion PET 
 
 
6/9/2014  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
1 
1. OBJECTIVES 
 
1.1 Study Design ‐ Abstract 
 
Arm 2: This study has two arms.  Arm 1 is the protocol as written below using Ammonia 
perfusion PET to assess ablation results of standard FDG PET/CT-guided liver tumor 
ablations. Arm 2 is the identical protocol, but substitutes the radiopharmaceutical FDG for 
Ammonia to assess ablation results of standard FDG PET/CT-guided liver tumor ablations. 
Arm 2 will not include the option of performing a second intraprocedural perfusion PET 
scan. FDG is FDA-approved for oncologic imaging as in this study. No IND or IND 
exemption is required. The protocol is identical in all other respects. All protocol 
comments pertaining to Arm 2 will be placed in new paragraphs beginning with “Arm 2:” 
in bold letters. Throughout the protocol, Arm 2 simply substitutes FDG for N-13 ammonia.  
In Arm 2, All AP-PET scans (which are the only research intervention of the study) are 
performed using FDG instead of N-13 ammonia.  
 
Arm 1 and Arm 2 are independent and no randomization or enrollment criteria for one arm 
or the other are defined. 
 
The purpose of this study is to evaluate a novel imaging technique for intra-procedural 
assessment, also known as monitoring, of image-guided percutaneous liver tumor 
microwave or cryoablation (thermal ablation) procedures.  Monitoring assures that the 
tumor is being ablated completely (and nearby critical structures left unharmed) by 
allowing the interventionalist to view ablative changes and make intra-procedural 
adjustments to the location of the ablation applicators, the number of overlapping ablation 
treatments, or the duration of ablation applications. As a result, improved monitoring has 
the potential to improve patient outcomes.  We will assess a novel method for monitoring 
18F-fluorodeoxyglucose (FDG) Positron Emission Tomography/Computed Tomography 
(PET/CT)-guided liver tumor ablations: intra-procedural 13N-ammonia perfusion PET (AP-
PET). N-13 ammonia is FDA-approved for cardiac perfusion imaging, but will be used in 
this study for the off-label indication of imaging perfusion of the liver.  The standard dose 
and IV route of administration will be employed. We will compare this method of 
assessing immediate technical success of ablation procedures to standard assessments 
using intra-procedural contrast-enhanced CT (CECT). We will also compare final intra-
procedural ammonia perfusion PET to gold standard 24-hour magnetic resonance imaging 
(MRI) or CT for predicting longer term technique effectiveness as demonstrated on routine 
MRI (or if MRI is not possible, on CT) obtained at a minimum of three to 12 months after 
the procedure. 
 
This study will evaluate if AP-PET can be used intra-procedurally during FDG PET/CT-
guided ablation procedures to identify regions of the ablation zone that do not adequately 
treat the tumor.  The ablation zone is the volume of tissue destroyed by the ablation 
treatment.  Adequate ablation treatment of tumor is generally defined by a minimum 
ablation margin of 5-10 mm. The ablation margin refers to the rim of normal tissue beyond 
the tumor included within the ablation zone in order to assure that even microscopic tumor 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
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2 
extensions beyond the visible tumor are fully destroyed.   
 
 
The ability to directly visualize and assess the ablation margin requires visibility of both 
the tumor and the boundaries of the ablation zone. Unfortunately, tumor visibility using CT 
or US is often lost or diminished immediately following thermal ablation.  On the other 
hand, the entire ablation zone is generally visible as a region of decreased or absent 
enhancement on CECT scans obtained following the ablation. The ablation zone is usually 
poorly defined on US imaging obtained after ablation.  Because of these limitations of CT 
and US, the ablation margin is usually estimated using side-by-side comparisons of the 
size and shape of the ablation zone as depicted on intra-procedural post-ablation CECT 
with the pre-procedural MRI or CT appearance and location of the tumor. Alternatively, 
retrospective software fusion of the post-ablation CECT with pre-procedural MRI or CT 
can be used. Unfortunately, these standard approaches often do not allow for confident 
point-by-point assessment of the entire circumference of the ablation margin.  These 
limitations of our standard imaging techniques for the intra-procedural assessment or 
monitoring of thermal ablation procedures in the liver underscore the need for identifying 
more robust techniques.  This study explores a novel imaging technique with the potential 
to improve our intra-procedural assessment of ablation results and, in turn, patient 
outcomes. 
 
Adult patients referred to our Tumor Ablation Clinic for image-guided percutaneous 
ablation of liver tumors will be considered for enrollment.  Patients who meet our standard 
clinical criteria for image-guided liver tumor ablations will be offered the opportunity to 
enroll in this prospective study. Standard clinical criteria include a known primary or 
metastatic malignancy of the liver for which local therapies are being considered. These 
may include tumors that are unresectable for any reason or tumors in patients who have co-
morbidities precluding surgery.  Liver tumor ablations are also performed to reduce the 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
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3 
tumor burden in patients with advanced disease or to palliate symptoms such as pain.  
Liver tumor ablation may serve as a bridge to liver transplantation in patients with 
hepatocellular carcinoma.  Ablation may be an option for patients who do not wish to 
undergo open surgical procedures.  It is expected that approximately 2/3 of the tumors will 
prove to be FDG-avid and 1/3 non-FDG-avid.  It is anticipated that we will ablate a single 
liver tumor per procedure in approximately 70% of patients, two liver tumors in 15% of 
patients, three liver tumors in 10% of patients, and more than three tumors in 5% of 
patients, based on our recent practice experience.  Patients will be excluded for 
uncorrectable coagulopathy or severe inter-current illness. Tumor ablation procedures will 
be performed as they are routinely performed by our team in clinical practice using FDG 
PET/CT and possible supplemental US guidance. Targeting can be accomplished based on 
tumor visibility on any one or more of these imaging modalities (US, PET, or CT).  FDG-
avidity is not essential for the targeting of tumors.  Patients enrolled in this study will 
receive ablation treatments that will not be compromised by the research portions of the 
procedures.  
 
The ablation will be planned and the ablation applicators inserted percutaneously using 
routine FDG PET/CT and possible supplemental US guidance. The ablation will then be 
performed using current protocols with either microwave ablation or cryoablation devices. 
Microwave ablation and cryoablation devices offer complimentary advantages that enable 
us to safely and effectively treat many liver tumors.  Cryoablation may be better tolerated 
and less painful when ablating liver tumors close to the liver capsule or diaphragm.  The 
iceball created during cryoablation is usually well visualized during the ablation, which 
can offer safety advantages when ablating near critical structures.  Microwave ablation has 
fewer tendencies to induce thrombocytopenia or myoglobinemia than cryoablation, which 
can be an advantage in patients with baseline thrombocytopenia or renal insufficiency.  
Microwave ablation is better able to overcome vascular heat-sink phenomena that can limit 
the ablation of tumor cells abutting large blood vessels.  Our standard practice is to choose 
the most appropriate ablation technology based on the individual patient’s specific 
circumstances.  Radiofrequency ablation is not included in this protocol, as microwave 
ablation has almost completely replaced the use of radiofrequency ablation in our practice.  
 
When the initial ablation is completed, intra-procedural AP-PET-1(research scan #1) will 
be performed and the findings recorded.  Specifically, the ablation margin separating the 
FDG-avid tumor from the normal ammonia-perfused liver will be assessed for visibility 
and thickness along the entire circumference. Patients with adequate renal function (EGFR 
>60) will then undergo intra-procedural contrast-enhanced CT, as is now performed in 
routine clinical practice to monitor initial results. Non-contrast CT will be used in cases of 
inadequate renal function or contrast allergy. If no additional overlapping ablation 
applications are deemed necessary or appropriate based on routine CT (Pathway 1), the 
procedure will be concluded at this point.  AP-PET information may be used to aid the 
margin assessment if CT is inconclusive.  Note that routine CT will always be used to 
determine the safety of additional overlapping ablation, per routine clinical practice.  This 
is because proximity of ablation devices to critical structures can only be imaged with CT 
and not with PET.  The patient will then undergo routine 24-hour post-procedure liver MRI 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
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This document is confidential. Do not disclose or use except as authorized. 
4 
or CT.  If the CT scan suggests an inadequate ablation margin of less than 5-10 mm at any 
portion of the tumor surface, additional ablations will be applied to the under-treated areas 
(Pathway 2), if deemed safe and appropriate based on standard clinical practice.  Then, 
AP-PET-2 will be repeated (research scan #2). Not more than two AP-PET scans will be 
performed during the entire procedure.  The AP-PET scan(s), illustrated schematically 
below, constitute the only research component of the protocol.  
 
Arm 2:  Arm 2 will not include the option of AP-PET 2 (research scan #2) due to the 
longer half-life of FDG.   
 
 
For patients with FDG-avid tumors, visibility rates of the entire ablation margin using AP-
PET-1will be compared to the visibility rates of the entire ablation margin using the intra-
procedural CECT scan.  Visibility rates using AP-PET-1 will also be compared to the 
visibility rates using the intra-procedural CECT scan fused to FDG PET (FDG 
PET/CECT).  The concordance rates of the final intra-procedural AP-PET (research scan 
#1 or #2) with gold standard 24-hour post-procedure MRI or CT will be determined.  
 
For those patients with non-FDG-avid tumors, retrospective software fusion of AP-PET-1 
with pre-procedural MRI or CT will be used to assess visibility rates of the ablation margin 
and will be compared with visibility rates of the ablation margin using retrospective fusion 
of the intra-procedural CECT and pre-procedural MRI or CT.  Similarly, in patients with 
non-FDG-avid tumors the concordance rate of final intra-procedural AP-PET (research 
scan #1 or #2) fused to pre-procedural MRI or CT, with gold standard 24-hour post-
procedure MRI or CT will be determined. The analysis of AP-PET utility in patients with 
non-FDG-avid tumors is a secondary objective of this study, but is nevertheless of interest, 
as AP-PET may prove valuable in these patients who cannot receive IV contrast or 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
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This document is confidential. Do not disclose or use except as authorized. 
5 
potentially as a superior assessment for patients who can receive IV contrast. Prediction of 
longer term technique effectiveness rates (local recurrence rates) based on blinded 
retrospective reads will be compared for the final intra-procedural AP-PET scan and 24-
hour MRI or CT, using local tumor progression as assessed on routine follow-up MRI or 
CT scans performed at least 3 to 12 months after the ablation procedure as the gold 
standard. Liver contrast-enhanced MRI is preferred for routine 24-hour follow-up imaging, 
however, contrast-enhanced CT may be substituted if the patient cannot undergo MRI due 
to contraindications such as incompatible implanted devices. 
 
The results of this study are expected to show that AP-PET can be used to reveal areas of 
ablation under-treatment or areas of optimal treatment that are not consistently identified 
with contrast-enhanced CT alone.  Better intra-procedural assessment of tumor ablation 
results has the potential to improve image-guided tumor ablation technical success and 
effectiveness rates. 
 
 
1.2 Primary Objectives  
 
Arm 2:  The primary and secondary objectives are identical for Arms 1 & 2 of the study 
(except that in Arm 2, no research scan #2 will be performed). 
 
• 1.  For FDG-avid tumors, compare the rates of complete, circumferential ablation margin 
visibility during FDG PET/CT-guided liver ablations using two imaging techniques: intra-
procedural AP-PET-1(research scan #1) and intra-procedural CECT. Discordance rates for 
complete ablation margin visibility between the two imaging techniques will be 
calculated. 
• 2.  For FDG-avid tumors, compare the rates of complete, circumferential ablation margin 
visibility during FDG PET/CT-guided liver ablations using two imaging techniques: intra-
procedural AP-PET-1 and intra-procedural CECT fused with FDG PET (FDG 
PET/CECT). Discordance rates for complete ablation margin visibility between the two 
imaging techniques will be calculated. 
• 3.  In assessing adequacy of the ablation margin for FDG-avid tumors, the concordance 
rates of final intra-procedural AP-PET(research scan #1 or #2) with gold standard 24-hour 
post-procedure MRI or CT will be determined. (Includes patients with renal insufficiency 
who cannot receive intra-procedural iodinated IV contrast.)  
• 4.  For non-FDG-avid tumors, compare the rates of complete, circumferential ablation 
margin visibility during FDG PET/CT-guided liver ablations using two imaging 
techniques: 1) intra-procedural AP-PET-1 fused to pre-procedural MRI or CT and 2) 
intra-procedural CECT fused to pre-procedural MRI or CT. Discordance rates for 
complete ablation margin visibility between the two imaging techniques will be 
calculated. 
• 5.  In assessing adequacy of the ablation margin for non-FDG-avid tumors, the 
concordance rate of final intra-procedural AP-PET (research scan #1 or #2) fused to pre-
procedural MRI or CT with gold standard 24-hour post-procedure MRI or CT will be 
determined. (Includes patients with renal insufficiency who cannot receive intra-

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procedural iodinated IV contrast.) 
 
 
 
 
1.3 Secondary Objectives 
 
• 1.  For FDG-avid tumors, rates of local tumor progression based on a minimum of 3-12 
month imaging follow-up will be compared for ablation margin adequacy assessed by 
blinded retrospective reads of final intraprocedural AP-PET (research scan #1 or #2) and 
24-hour post-procedure MRI or CT. (Includes patients with renal insufficiency who 
cannot receive intra-procedural iodinated IV contrast.) 
 
 
2. BACKGROUND 
 
2.1 Study Agent(s) 
 
• No therapeutic drugs are involved in this study. The nuclear imaging radiopharmaceutical 
N-13 ammonia is an FDA-approved radiotracer that will be used for an off-label 
diagnostic imaging indication.  The tracer will be administered by the standard IV route 
and using the standard 10 mCi dose.  Instead of imaging perfusion of the heart (FDA-
approved indication), the tracer will be used in this study to image perfusion of the liver 
(off-label indication).   
• Arm (2): FDG will be used not only for the routine targeting phase of the procedure but 
also as the perfusion agent instead of N-13 ammonia.  FDG is FDA-approved for 
oncologic imaging as in this study.  The total FDG dose including the targeting dose (8-10 
mCi) and the research perfusion dose (2-4 mCi) will together fall within the standard dose 
for routine diagnostic or interventional FDG PET/CT scans (< 15 mCi). This “split-dose” 
technique allows the research PET perfusion scan to be performed without adding to the 
routine FDG dose received by patients not undergoing the research PET perfusion scan.  
 
2.2 Study Disease 
 
• Liver tumors, including primary or metastatic malignancies. 
 
2.3 Rationale and Correlative Studies Background 
• Percutaneous image-guided thermal ablation procedures are increasingly 
used to treat liver tumors (1).  These procedures are most commonly 
performed using US or CT guidance.  Not all tumors are well-visualized 
using CT and/or US guidance, which has prompted the increasing use of 
PET/CT for guidance of percutaneous interventional procedures. PET/CT-

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guided tumor ablations are becoming more common due the advantage of 
targeting tumors not visible using other imaging techniques and targeting 
tumors based on metabolic characteristics (2-4).  This allows for targeting of 
specific regions of tumors based on viability, glucose metabolic activity, and 
other biologic characteristics (e.g. hypoxia, DNA synthetic activity). 
• Regardless of the imaging guidance modality used, monitoring the ablation is 
important to assure that the tumor and a sufficient margin of surrounding 
normal liver are ablated.  An adequate ablation margin minimizes the risk of 
local tumor recurrence.  It is an accepted, important goal of all liver tumor 
ablations that the ablation zone extends least 5-10 mm beyond the tumor at 
all points of the tumor surface (1). This assures that microscopic disease just 
outside the visible tumor is treated.  The ablation margin surrounding the 
tumor is analogous to a surgical margin that provides confidence the entire 
tumor has been removed including microscopic extensions into adjacent 
normal tissues. 
• Current techniques for intra-procedural assessment of tumor ablation margins have 
limitations.  For example, when performing CT-guided ablations, it is standard practice to 
obtain an intra-procedural contrast-enhanced CT (CECT) to monitor whether the tumor is 
being treated fully and an adequate ablation margin is being obtained following thermal 
ablation.  CECT is usually performed only once near the end of the procedure since one 
dose of IV contrast material is usually the limit for a 24-hour period.  If a reduced dose of 
IV contrast is used, this may allow for two intra-procedural CECT scans, however, this 
may limit the effectiveness of the method. For example, the degree of liver enhancement 
is reduced making it difficult to distinguish tumor from liver.  Patients with a contrast 
material allergy or severe renal insufficiency (EGFR < 30) are often not considered 
candidates for CECT.  An additional limitation of CECT in the assessment of liver tumor 
ablations is that once ablated, the tumor is usually difficult to distinguish from the 
surrounding ablated normal liver tissue.  Consequently, direct visualization of the 
ablation margin is often not possible using CECT.  US is even less effective in assessing 
ablation results in that tumor visibility is rapidly obscured by the developing ablation 
zone and the ablation zone margins are usually indistinct.  For liver tumors, MRI 
performs better in depicting not only the exact borders of the ablation zone, but also in 
showing the residual tumor.  As a result, 24-hour follow-up MRI with contrast can be an 
effective method for confirming the thickness or size of the ablation margin.  Follow-up 
MRI, however, does not allow for intra-procedural assessment of ablation results during 
US, CT, or PET/CT-guided ablations that might prompt immediate further treatment 
while the patient is still on the scanner table. 
• An effective imaging technique for monitoring ablations that can be safely performed 
repeatedly during ablation procedures is needed. 
• We have previously shown that, during PET/CT-guided tumor ablation procedures, tumor 
FDG activity is not dissipated by thermal ablation, whether through heating or freezing 
(2).  Tumor FDG activity remains unperturbed following ablation allowing for continued 
excellent PET visibility of the tumor for hours after the procedure.  This unique feature of 
PET imaging can potentially be used to help monitor the thickness of the ablation zone 

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margin.  One option is to incorporate CECT into the PET/CT protocol for assessing 
ablation results.  In this scenario, the ablated tumor is depicted by FDG avidity on PET, 
whereas the ablation zone is defined using CECT, all obtained as a combined PET/CT 
protocol.  The drawback of this approach is the potential for PET/CT image 
misregistration, for example, misalignment of anatomical structures as depicted on the 
PET acquisition when compared to the CT acquisition of the PET/CT scan, resulting 
from respiratory motion. PET offers an alternative to CECT in defining the ablation zone.  
Perfusion PET using a very short half-life radiopharmaceutical, N-13 ammonia, can also 
demonstrate the ablation zone due to its utility as a perfusion imaging agent.  N-13 
ammonia is primarily used for myocardial perfusion imaging, but is also known to 
demonstrate liver perfusion well (5-8). Below are images from a cardiac ammonia 
perfusion PET study (note excellent liver perfusion activity). 
 
 
 
• Since all ablations, including microwave ablation or cryoablation, reduce or eliminate 
blood perfusion throughout the ablation zone, PET/CT can be used to define the ablation 
zone as a hypo-perfused region using the FDA-approved PET perfusion agent 13N-
ammonia. Unablated liver remains perfused whereas the ablation zone does not.  The 
ablation zone then appears as a photopenic region surrounded by radiopharmaceutical 
uptake in the unablated, perfused parenchyma.  In the scenario of a successful FDG 
PET/CT-guided thermal ablation of a liver tumor, the expected appearance during AP-
PET would be a target pattern. The ablated tumor retains FDG activity and would form 
the center “hot spot” of the target.  The ablation zone margin would appear as a “cold” 
ring due to minimal FDG activity and absence of perfusion by N-13 ammonia.  The outer 
surrounding unablated liver would appear “hot” due to perfusion by N-13 ammonia.  In 
the scenario of an unsuccessful FDG PET/CT-guided ablation, the ablation margin 

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depicted as a “cold” rim would either be absent or incomplete, indicating an inadequate 
ablation margin. AP-PET would be obtained using a radiopharmaceutical administration 
protocol identical to our standard cardiac practice.  PET image acquisition will be 
obtained dynamically, as the N-13 ammonia is injected intravenously, using 15 second 
frames over 5 minutes. 
 
• The advantages of using AP-PET to define the adequacy of the ablation zone margin 
include a very low radiation dose to the patient, substantially less than a diagnostic CT 
scan and approximately one-tenth the dose from FDG PET, using equal administered 
activity (9).  AP-PET is thus an ideal intraprocedural monitoring method that can be used 
repeatedly.  Incorporating CECT into the PET/CT protocol could be used to assess the 
ablation zone margin relative to the FDG-avid tumor, but is subject to the problem of 
misregistration of the PET and CT images (3).  In other words, the PET and CT 
components of a PET/CT scan are acquired at different time points and may not line up 
perfectly with each other, for example, due to respiratory motion between the PET and 
CT scans.  Using FDG PET to visualize the ablated tumor and AP-PET to visualize the 
perfused tissue eliminates the issue of misregistration, since both are imaged at the same 
time and in the same position using a single PET scan. 
 
• Arm 2: The advantages of using FDG as the perfusion agent for the AP-PET scan 
include that it does not require an on-site cyclotron – thus the technique has the potential 
for wide applicability.  FDG is used in clinical practice during tumor ablation procedures 
in a split-dose fashion, dividing a standard dose into two parts: one for the targeting phase 
of the procedure and one for the final assessment phase of the procedure.  This keeps the 
total radiation dose within that of a standard diagnostic PET/CT scan. 
 
• Our Nuclear Medicine physicists at BWH have performed a PET/CT phantom study (see 
images below) that created compartments simulating the expected radioactivity 
concentrations in normal liver, the ablation margin, and the tumor that support the 
potential of AP-PET to demonstrate the ablation margin of FDG-avid tumors even with 
acquisitions as short as 30 seconds. The ablation margin appears as a dark ring around the 
FDG-avid tumor.  Surrounding normal liver remains perfused by activity. 
 
 

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• This study will assess the rates of complete ablation margin visibility using 
AP-PET alone in comparison to CECT alone or fused PET/CECT.  This 
study will assess the concordance of final intraprocedural assessment of 
tumor ablation results using AP-PET with results observed on gold standard 
24-hour contrast-enhanced MRI or CT.   
• Patients may benefit from participation in this study if AP-PET can be used 
to identify an inadequate ablation margin not evident on CECT or in 
patients who cannot undergo CECT and are scanned without contrast.  In 
such cases, additional overlapping ablations may be performed during the 
same procedure and thus increase the chance of technical success (complete 
tumor ablation rate) and technique effectiveness (low local recurrence rate).  
The safety of any additional ablation applications would be based on routine 
intraprocedural CT scans per standard practice. 
 
3. PARTICIPANT SELECTION 
 
3.1 Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
• Adults, 18 years or older 

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• Referral from an internist, oncologist, or surgeon for liver tumor ablation 
consultation 
• ECOG Performance Status < 3 
• Liver tumor ablation judged to be appropriate based on clinical assessment 
in the BWH Tumor Ablation Clinic by the tumor ablation interventional 
radiologist, per standard clinical practice 
• Ability to understand and the willingness to sign a written informed 
consent document. 
 
3.2 Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be 
eligible for admission into the study. (Each are relative contraindications to ablation in 
current clinical practice.) 
o Uncorrectable coagulopathy (due to bleeding risk) 
o Pulmonary disease precluding monitored anesthesia care or general 
anesthesia 
o Severe renal insufficiency, EGFR < 30 
o Uncontrolled intercurrent illness including, but not limited to 
ongoing or active infection, symptomatic congestive heart failure, 
unstable angina pectoris, significant cardiac arrhythmia, or 
psychiatric illness/social situations that would limit compliance 
with study requirements. 
o Childs-Pugh Class C cirrhosis 
o Occlusive main portal vein thrombosis 
o Presence of biliary-enteric anastomosis (due to risk of biliary 
infection) 
o Pregnant women are excluded (because both CT and PET/CT 
scans involve the use of ionizing radiation which may pose a 
potential teratogenic effect on the fetus.) 
 
 
3.3 Inclusion of Women, Minorities and Other Underrepresented 
Populations 
 
• This study will enroll patients with primary or secondary liver tumors based on referral 
for image-guided tumor ablation.  Patient enrollment will not be based on sex, ethnicity, 
or race.  Patients from underrepresented populations with a potentially higher incidence 
of cirrhosis and HCC will be enrolled using the same criteria as for all other patients.  
The study design is not expected to impose limitations on any particular subpopulation. 
 
• The patient will be referred by a treating internist, oncologist, or surgeon, at DFCI or 
BWH involved in managing the patient’s liver tumor(s), for image-guided thermal 

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ablation.  The patient must be evaluated by one of the interventional radiologists, 
investigator or co-investigator on this protocol, who perform liver tumor ablation 
procedures at BWH, and must be deemed a suitable candidate for the procedure(s) and 
based on our standard clinical practice.  

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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 day of the procedure. Any participant not registered to the protocol 
before the procedure 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 undergo the ablation procedure protocol. 
Issues that would cause treatment delays should be discussed with the Principal 
Investigator. If a participant does not meet protocol requirements, 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: 
 
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. 

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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. 
 
 
4.3 General Guidelines for Other Participating Institutions ‐ N/A 
 
4.4 Registration Process for Other Participating Institutions ‐ N/A 
 
5. TREATMENT PLAN 
 
The treatment plan for this study involves the non‐therapeutic 
administration of a radiopharmaceutical, N‐13 ammonia, one 
to two doses, during the tumor ablation procedure.  The N‐13 
ammonia perfusion PET scan is a diagnostic imaging test.  The 
tumor ablation procedure is performed according to our 
standard clinical practice and is not itself a research activity.  
The use of N‐13 ammonia to image liver perfusion with a PET 
scanner is the research portion of the procedure.  The patient 
will receive one or two doses of N‐13 ammonia (10 mCi/dose) 
for intraprocedural assessment of ablation results. Not more 
than two doses will be administered and one or both doses will 
be administered on the day of the tumor ablation procedure 
only. 
 
 
 
 
Arm 2: FDG is used instead of N-13 ammonia for the research PET scan.  Only one  
Perfusion PET scan with FDG will be performed.  The FDG dose will be divided, using 
8-12 mCi for targeting and 2-5 mCi for the perfusion scan.  The total FDG dose will not 
exceed a standard FDG dose (≤ 15 mCi) used for routine diagnostic PET/CT scans or 
interventional PET/CT procedures. 
 
6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE 
MODIFICATIONS  
 

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There are no expected toxicities related to the IV 
administration of the N‐13 ammonia radiopharmaceutical, 
however, the radiopharmaceutical is associated with a small 
radiation dose to the patient.  Each 10 mCi dose of N‐13 
ammonia delivers an effective dose to the patient of 
approximately 0.74 mSv.  The accompanying CT dose is 0.6 
mSv for each ammonia PET/CT scan.  Accordingly, the patient 
will receive an effective dose of 1.34 mSv if a single N‐13 
ammonia scan is performed and 2.68 mSv if two scans are 
performed.  This is compared with an annual estimated 
background radiation dose associated with living in the U.S. of 
3.5 mSv. No dosing delays or modifications are anticipated, 
however, if a dose cannot be obtained due to technical issues, 
the patient’s procedure would be completed per standard 
clinical practice and would not be adversely impacted by the 
inability to perform the ammonia PET scan.  If the patient did 
not receive the N‐13 ammonia dose during the procedure, they 
would no longer be eligible to participate in the study. 
 
Arm 2: In Arm 2 of the study, FDG is used instead of N-13 ammonia for the perfusion 
scan.  The FDG will be administered using our standard clinical practice of splitting the 
FDG dose into a targeting dose (8-12 mCi) and a perfusion dose (2-5 mCi), so that the 
total dose does not exceed a routine FDG dose used for diagnostic PET/CT scans (≤ 15 
mCi).  Accordingly, the patient will not receive more radiation dose than they would if 
not participating in this research protocol; the radiation dose will be identical to a 
routine FDG PET/CT-guided ablation procedure. 
7. DRUG FORMULATION AND ADMINISTRATION  
 
N-13 ammonia production overview (not required for FDG production, as this is FDA-
approved for the study indication) 
 
The radiopharmaceutical, N-13 ammonia, is prepared by the BICOR on-site 
cyclotron/radiopharmacy facility at BWH. Brigham and Women’s Hospital produces N-13 
ammonia in a cyclotron target by proton irradiation of natural water with added ethyl alcohol.  
The irradiated solution is passed through an anion exchange column to remove extraneous anions 
and [13N] Ammonia is captured on a cation exchange column while the target water passes to a 
waste vial.  Normal saline is used to elute the [13N] Ammonia and is sterile filtered into the 
product container.  Sub-lots are produced each day in accordance with patient needs.  The first 

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sub-lot is used exclusively for quality release testing.  Subsequent lots are visually inspected and 
assayed.  All sub-lots have individual sterile filters, each of which is integrity tested. 
 
Proton Irradiation 
Anion Exchange Cleanup 
Sterile filtration 
Target Fill 
Gamma Spec 
HPLC 
pH 
T½  
< QC – Product > 
Pass/Fail 
Fail - Reject
Target Water Preparation 
Drug Product 
[13N]-Ammonia
Drug Product 
Delivery to Hot Cell 
Filter Membrane 
Visual 
Sterility 
Pyrogenicity
Cation Capture 
Target Water Waste
Sterile Normal Saline 
Elution 
Filter Membrane 
Visual 

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Cyclotron and Target Preparation 
 
Target water is prepared by mixing 145 uL of ethyl alcohol to 50 mL of LAL water.  The target 
contains 1.5 mL of solution.  The prepared vial supplies all target-fills for a day’s production.  
Hot Cell Preparation 
 
The target water delivery from the cyclotron leads to a clean hot cell (HC) where it is connected 
to the input of the [13N] Ammonia purification apparatus.  The columns in the apparatus are 
conditioned and assembled with the final product vial kit prior to closing the hot cell.  Product 
vial kits are prepared in a sterile enclosure, one setup for each sub lot.    
Table 1. 
Ammonia Chemistry Setup Components 
Item 
Quantity 
Specification 
Ammonia Kit  
1 
M0021 
Maxi-Clean SAX cartridge 
1 
SB M0143 
Sep Pak Accell Plus CM 
1 
SB M0178 
LAL Water 
20 mL 
SB C0084 
Product Filtering Y 
2 
SB M0123 
0.9% Sodium Chloride Syringe 10mL 
1 
SB C0139 
Acrodisc 0.2 um 32 mm 
1 
SB M0131 
Four Way Stopcock 
1 
SB M0009 
 
Table 2. 
Ammonia Chemistry Setup Components 
Item 
Quantity 
Specification 
Ammonia Kit  
1 
M0021 
Maxi-Clean SAX cartridge 
1 
SB M0143 
Sep Pak Accell Plus CM 
1 
SB M0178 
LAL Water 
20 mL 
SB C0084 
Product Filtering Y 
2 
SB M0123 
0.9% Sodium Chloride Syringe 10mL 
1 
SB C0139 
Acrodisc 0.2 um 32 mm 
1 
SB M0131 
Four Way Stopcock 
1 
SB M0009 
 

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Target Irradiation 
 
The process to make [13N]-Ammonia is irradiation of the target with 16.5 MeV protons.  The 
proton current is set at 35 uAmp and the irradiation time is 15 minutes.  The reaction 16O(p,α)13N 
produces 13N ions that capture hydrogen from dissolved ethyl alcohol to form Ammonia 
([13N]NH3).  At the end of bombardment, the target water is transferred and the target dried. 
Post Irradiation Handling 
The target water passes through the anion and cation columns before being diverted to the waste 
water collection vial leaving [13N]-Ammonia captured on the cation column.  10 mL of normal 
saline elutes the [13N]-Ammonia and passes through a sterilizing filter and into the final product 
vial.  The first sub lot of the day is used only for quality control testing.   
Table 3. 
[13N]-Ammonia Composition for each Sub-lot 
Item 
Quantity 
Concentration 
Sterile Normal Saline 
for Injection 
8 -10 ml 
9.0 mg/mL  
[13N]-Ammonia 
30 to 375 mCi 
3.75 to 37.5 mCi/mL 
 
Analytical Procedures (N-13 ammonia injection) 
[13N]-Ammonia quality control testing is conducted on material collected from the first 
irradiation (sub-lot) of a day’s production.  Samples are drawn and one part tested in the clean 
areas and the other sample taken to the quality testing lab for analysis 
 

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Table 4. 
Summary of Analytical Procedures for Release Testing 
Attribute 
Procedure 
Requirement 
Appearance 
Q0119, Visual Inspection of 
Clear Solution 
Clear, colorless and particulate free 
 
Radionuclidic 
Identity 
Q0118, Radionuclide Identity 
– T1/2 
Half-life is between 9.5 and 10.5 
minutes 
Radiochemical 
Identity 
Q0041, [13N]-Ammonia 
Radiochemical & Chemical 
Purity by HPLC 
Determine retention times of product 
and reference standard.  Ratio of 
retention times is 1.12 ± 5% 
Radiochemical 
Purity and 
Chemical Purity 
Q0041, [13N]-Ammonia 
Radiochemical & Chemical 
Purity by HPLC 
Radiochemical Purity ≥95% 
No unknown chemical peaks 
identified 
Radionuclidic 
Purity 
Q0042, [13N]-Ammonia 
Radionuclidic Purity by MCA
≥99.5% of radiation associated with 
511 Kev 
Radioactive 
Concentration 
M0009, [13N]-Ammonia 
Batch Release Record 
3.75 to 37.5 mCi/mL  
Specific Activity 
NA – No Carrier Added 
NA 
pH 
Q0045, [13N] Ammonia pH 
Testing 
4.5-7.5 (USP) 
Filter Integrity 
Q0117 Filter Integrity Testing
≥45 psi bubble point 
Pyrogenicity  
(Bacterial 
Endotoxins) 
Q0044, Pyrogen Testing 
<175EU/V  
Sterility 
Q0043, Sterility Testing 
No growth after 14 days 
 
Dose administration 
The final dose-calibrated, sterile radiopharmaceutical is delivered to the AMIGO suite in a single 
syringe for intravenous administration through the patient’s existing IV access. 
  
8. CORRELATIVE/SPECIAL STUDIES – N/A 
9. STUDY CALENDAR 
 
• All research activity requiring patient participation occurs during the image-guided liver 
thermal ablation procedure on day 1.  The only research activities are the one or two 
perfusion PET scans on day 1.  All other calendar events fall within our routine clinical 
practice. 

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• Arm 2: the calendar for Arm 2 is identical to Arm 1; FDG PET/CT is substituted for 
Ammonia PET/CT 
• Follow-up imaging examinations are performed as part of routine clinical practice and 
do not require extra patient time or commitment. 
 
Visit 1 
Visit 2
Visit 3
Visit 4 
 
Screening Day 1
Day 2-
30
Day 
90-365 
Medical History & 
Physical Exam 
X 
 
 
 
Blood Test 
X 
 
 
 
Pregnancy Test 
X 
 
 
 
Liver tumor 
ablation 
 
X 
 
 
Perfusion PET/CT
 
X 
 
 
MRI, CT or 
PET/CT scan 
 
 
X 
X 
 
 
 
10. MEASUREMENT OF EFFECT 
 
Drug response is not an endpoint of this trial.  No therapeutic drugs are investigated in 
this trial.  Patients undergoing liver ablation procedures will undergo follow-up contrast-
enhanced MRI or CT at 24 hours (but not more than 30 days) after the ablation and then 
at 3-months to one year after the ablation.  While obtaining a contrast-enhanced MRI or 
CT is routinely performed by our team at 24 hours, there are occasionally patient-specific 
clinical factors that may make it preferable to obtain the initial post-procedure scan up to 
30 days later.  This does not compromise our assessment of study endpoints. Then at least 
one scan is obtained between 3-months and one year, depending on routine clinical 
requirements.  If there is severe renal insufficiency with EGFR < 30, the patient cannot 
be enrolled.  CT and MRI with contrast can be performed with an EGFR ≥ 30.  The 
assessment for incomplete tumor ablation and local tumor recurrence following thermal 
ablation procedures are study endpoints that are not based on standardized response 
criteria, such as RECIST.  Instead, the interpretation of follow-up imaging tests is based 
on identification of findings that are now known to be specific for residual or recurrent 
tumor.  These include new or enlarging nodular enhancing masses either in the ablation 
zone or at its margins.  Enlargement of the ablation zone compared to baseline post-
ablation imaging is a suspicious finding.  Suspicious findings may undergo biopsy when 
possible and clinically indicated to prove the presence of tumor.  Progressive imaging 
findings will be a secondary criterion for local tumor recurrence when biopsy is not 
clinically indicated.  Other clinical parameters, such as serum tumor markers, cannot be 
used as the sole indication that the treated tumor was not treated completely because the 
marker activity could emanate from other liver tumors or tumor outside the liver. Thus 
serum tumor markers will not provide direct evidence of local tumor recurrence, but may 

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provide supportive evidence. 
 
 
11. ADVERSE EVENT REPORTING REQUIREMENTS 
11.1 Definitions 
Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or experience 
that develops or worsens in severity after enrollment into the study protocol 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.  
Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring during the protocol and 
regardless of causality that:  
 
• Results in death 
• Is life-threatening. Life-threatening means that the person is 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 requires 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 result in inpatient hospitalization, or the development of 
drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 

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• 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 does not worsen 
• emergency outpatient treatment for an event not fulfilling the serious criteria outlined 
above and not resulting in inpatient admission 
• respite care 
 
Expectedness 
• Adverse events can be 'Expected' or 'Unexpected.'  
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). 
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. 
11.2 Procedures for AE and SAE Recording and Reporting 
 

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• 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, 
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.  
 
11.3 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.  
11.4 Reporting to the Study Sponsor 
Serious Adverse Event Reporting 
 
• All serious adverse events that occur immediately after, during, or within 30 days of 
the research AP-PET scans 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. 

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 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.  
 
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: 
 
Paul B. Shyn, MD  
 
817-996-7208 (cell) 
 
pshyn@partners.org  
 
617-732-8353 (office) 
 
• 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. 
11.5 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). 
 
•  Other investigative sites should report serious adverse events to their respective IRB 
according to the local IRB’s policies and procedures in reporting adverse events. A 
copy of the submitted institutional SAE form should be forwarded to:  N/A 
 
 

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• The DF/HCC Principal Investigator will submit SAE reports from outside institutions to 
the DFCI Office for Human Research Studies (OHRS) according to DFCI IRB policies 
and procedures in reporting adverse events.   N/A 
11.6 Reporting to the Food and Drug Administration (FDA) 
 
 
 
•  N/A 
11.7 Reporting to the NIH Office of Biotechnology Activities (OBA) 
 
 
  
•  N/A 
11.8 Reporting to the Institutional Biosafety Committee (IBC)N/A 
 
• N/A 
11.9 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. 
11.10 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.  

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12. DATA AND SAFETY MONITORING 
 

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12.1 Data Reporting 
Method  
After review and approval by the QACT manager, Wendy Magnan, MPH, 
the decision was made that QACT will not collect, manage, or monitor 
data for this study. Note that this is not a therapeutic drug trial.  The 
research activity involves only the IV administration of the PET 
radiopharmaceutical N-13 Ammonia or FDG.  Instead, data will be 
collected and managed by the P.I. using a REDCap database. 
 
12.2 Safety Meetings 
 
 
• The DF/HCC Data and Safety Monitoring Committee (DSMC) will review the 
protocol up to four times a year to review toxicity and accrual data. Information to be 
provided to the committee may include: up-to-date participant accrual; current dose 
level information;  all grade 2 or higher unexpected adverse events that have been 
reported; summary of all deaths occurring with 30 days of intervention; 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. 
 
 
12.3 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, 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.  
 
13. REGULATORY CONSIDERATIONS 

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13.1 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. 
13.2 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.  
 
 
13.3 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 
o Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr11_02.html 

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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.  
13.4 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.  
• Photographs may be taken during the ablation procedures for illustration purposes in 
scientific publications or meetings, however, such photographs will not include the 
patient’s face and will not in any way identify the patient. 
13.5 Records Retention 
 
• All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  

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13.6 Multi‐center Guidelines – N/A 
13.7 Cooperative Research and Development Agreement (CRADA)/Clinical 
Trials Agreement (CTA) – N/A 
 

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14. STATISTICAL CONSIDERATIONS 
 
 
 
14.1 Study Design/Endpoints 
 
Arm 2: Study design/endpoints are identical for Arms 1 & 2. 
 
In this study of patients with liver lesions, it is expected that roughly two-thirds of patients will 
have FDG-avid tumors, one-third of patients will have non FDG-avid tumors, and although it is 
possible for a patient to have both types of tumor, that is considered rare. For sample size and 
power considerations we therefore conservatively assume that patients will have one type of 
tumor or the other and therefore target a sample size of 100 patients per arm, allowing for the 
potential for renal insufficiency in up to 25% of all patients (described in more detail below). 
Also, as the techniques focus on analysis by tumor and it is estimated that 70% of patients will 
have only a single lesion, the sample size considerations will focus on enrolling patients rather 
than tumors. Multiple tumors per patient, when they occur, will be treated and assessed in the 
statistical analysis, with appropriate adjustment for clustering of tumors within a patient to 
account for correlation of responses within a patient. Sample size considerations, however, focus 
on enrollment of patients. The study design and endpoints are identical for Arm 1 and Arm 2. 
 
 
Primary Objectives: 
 
1.  Among FDG-avid liver tumors, comparison of imaging techniques will be done on paired 
tumor samples using McNemar’s test, focusing on discordant pairs (AP-PET-1 adequate/CECT 
inadequate and AP-PET-1 inadequate/CECT adequate). For these comparisons it is expected that 
the rate of discordance will be high (near 60% of all pairs) and that differential in discordance 
will be large (difference between discordant pairs on the order of 50% or higher). In addition to 
comparing discordant pairs, there is interest in being able to precisely estimate the visibility rates 
under each imaging modality. With 50 paired samples in the FDG-avid liver tumor ablation 
group in each arm, visibility of the entire ablation margin can be estimated with a 95% binomial 
confidence interval that should be no wider than 24 percentage points (+/- 12%) in the expected 
range of visibility of each modality (80% for AP-PET and 20% for CECT). This sample size will 
provide greater than 90% power for McNemar’s test using a 5% type I error given the 
assumptions above about discordance.  
 
Since both imaging modalities are required for McNemar’s test and the rate of renal 
insufficiency that would preclude a paired CECT scan is estimated to be roughly 25%, inflation 
for loss due to patients with renal insufficiency implies that the FDG-avid tumor target sample 
size for this trial is 67 patients per arm (=50/0.75). The trial will be monitored closely for 

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potential early closure if the rate of renal insufficiency is lower than 25% or potential extension 
of accrual if the yield of paired samples is lower than 75%.  
 
2.  With at least 50 evaluations in the FDG-avid liver tumor treated group per arm, the visibility 
rates for AP-PET-1 and intra-procedural PET/CECT will be estimated with an accuracy of +/- 
12% using 95% confidence intervals for binomial proportions. With this sample size, if the 
observed visibility rate is near 90%, the 95% confidence interval width is expected to be shorter 
than 19 percentage points. 
 
3.  In patients with FDG-avid liver tumors, the goal of this objective is to assess the proportion of 
cases confirmed to have adequate ablation margins using 24-hour MRI or CT as the gold 
standard among those identified as nominally adequate at the time of final intra-procedural 
imaging. Note that for this objective, patients do not have to receive intra-procedural iodinated 
IV contrast, hence the reduction in sample size due to renal insufficiency does not apply to this 
objective.  It is expected that nearly 95% of cases will be identified as nominally adequate by all 
available post-ablation intra-procedural imaging data (i.e. standard-of-care imaging plus AP-
PET). With 75 cases per arm, this translates to roughly 71 nominally adequate cases. Among 
these cases, the ablation margin adequacy rates based on 24-hour MRI or CT will be estimated 
with 95% binomial confidence intervals and it is expected that the adequacy rates for all 
available post-ablation intra-procedural imaging will be high, in the range of 90% or higher. 
With the sample size stated above, the 95% confidence intervals to confirm adequate ablation 
after 24 hours will be no wider than 16 percentage points (+/- 8%). It is also of interest to 
confirm that margins that were deemed inadequate on AP-PET alone were confirmed inadequate 
based on 24-hour MRI or CT but this objective is largely exploratory since the sample size for 
cases labeled inadequate after AP-PET is expected to be very low, only 5% of the total cases. 
Finally, it is of interest to assess agreement of final intra-procedural AP-PET with 24-hour MRI 
or CT. Concordance rates are unknown but are estimated to be in the range of 50 to 80%. With 
75 cases per arm, the 95% confidence intervals on the concordance rates are expected to be no 
wider than 24 percentage points (+/- 12%) assuming, conservatively, that the true concordance 
rate is near 50%. 
 
4.  Among non FDG-avid tumors (expected to be one-third of patient accrual) comparison of 
imaging techniques will be done on paired samples using McNemar’s test, focusing on 
discordant pairs (AP-PET fused to pre-procedural MRI or CT adequate/CECT fused to pre-
procedural MRI or CT inadequate and AP-PET fused to pre-procedural MRI or CT 
inadequate/CECT fused to pre-procedural MRI of CT adequate). For these comparisons it is 
expected that the rate of discordance will be high (near 70% of all pairs) and that differential in 
discordance will be large (difference between discordant pairs on the order of 60%). In addition 
to comparing discordant pairs, there is interest in being able to precisely estimate the visibility 
rates under each imaging modality. With 25 paired samples per arm in the non FDG-avid liver 
tumor ablation group, visibility of the entire ablation margin can be estimated with a 95% 
binomial confidence interval that should be no wider than 34 percentage points (+/- 17%) in the 
expected range of visibility of each modality (80% for AP-PET and 20% for CECT). This 
sample size will provide greater than 90% power for McNemar’s test using a 5% type I error 
given the assumptions above about discordance.  

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Since both imaging modalities are required for McNemar’s test and the rate of renal 
insufficiency that would preclude a paired CECT scan is estimated to be roughly 25%, inflation 
for loss due to patients with renal insufficiency implies that the non FDG-avid tumor target 
sample size for this trial is 33 patients per arm (=25/0.75). The trial will be monitored closely for 
potential early closure if the rate of renal insufficiency is lower than 25% or potential extension 
of accrual if the yield of paired samples is lower than 75%.  
 
5. In patients with non FDG-avid liver tumors, the goal of this objective is to assess the 
proportion of cases confirmed to have adequate ablation margins using 24-hour MRI or CT as 
the gold standard among those identified as nominally adequate at the time of final intra-
procedural imaging. Patients evaluated for this objective do not have to receive intra-procedural 
iodinated IV contrast.  It is expected that nearly 95% of cases will be identified as nominally 
adequate by all available post-ablation intra-procedural imaging data (i.e. standard-of-care 
imaging plus AP-PET). With 33 cases per arm, this translates to roughly 31 nominally adequate 
cases. Among these cases, the ablation margin adequacy rates based on 24-hour MRI or CT will 
be estimated with 95% binomial confidence intervals and it is expected that the adequacy rates 
for all available post-ablation intra-procedural imaging will be high, in the range of 90% or 
higher. With the sample size stated above, the 95% confidence intervals to confirm adequate 
ablation after 24 hours will be no wider than 24 percentage points (+/- 12%). It is also of interest 
to confirm that margins that were deemed inadequate on AP-PET fused to pre-procedural MRI or 
CT were confirmed inadequate based on 24-hour MRI or CT but this objective is largely 
exploratory since the sample size for cases labeled inadequate after AP-PET fused to pre-
procedural MRI or CT is expected to be very low, only 5% of the total cases. Finally, it is of 
interest to assess agreement of final intraprocedural AP/FDG PET fused to pre-procedural MRI 
or CT with 24-hour MRI or CT. Concordance rates are unknown but are estimated to be in the 
range of 50 to 80%. With 33 cases per arm, the 95% confidence intervals on the concordance 
rates are expected to be no wider than 36 percentage points (+/- 18%) assuming, conservatively, 
that the true concordance rate is near 50%.  
 
Secondary Objectives: 
 
Within arm, comparison of local tumor progression rates to ablation margin adequacy will be 
largely descriptive as this study does not have adequate power to make definitive conclusions 
about progression rates. Given the expected heterogeneity of the treated liver tumor populations 
at presentation and potential variability in clinical follow-up for local progression, this objective 
is therefore largely exploratory. Intra-procedural IV iodinated contrast is not required for patients 
analyzed for this objective.  An independent radiologist will perform blinded reads for both the 
final intraprocedural AP-PET and 24-hour MRI or CT to classify cases as adequate or inadequate 
with respect to the ablation margins for both imaging techniques. Cases will be followed 
clinically for at least 3-12 months to identify local tumor progression. The method of Kaplan and 
Meier will be used to estimate the censored time-to-failure distributions for local tumor 
progression with the goal of estimating, in a preliminary and exploratory fashion, the local tumor 
progression rates by adequacy of the blinded AP-PET and 24-hour MRI or CT reads.  Statistical 

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precision will be limited for these evaluations and no formal comparison of groups will be 
performed. 
 
14.2 Sample Size/Accrual Rate 
Target enrollment for each arm of the study is 100 patients.  Each patient 
will be followed for 12 months after their study procedure(s).  An accrual 
rate of 3-6 subjects/month is anticipated.  Enrollment of 200 total patients is 
expected to be completed within 3-4 years. 
 
14.3 Stratification Factors – N/A 
 
14.4 Analysis of Secondary Endpoints 
 
See above, Section 14.1 
 
14.5 Reporting and Exclusions 
 
This is not a therapeutic drug trial.  Please see Section 14.1 
 
15. PUBLICATION PLAN 
 
The principal investigator holds primary responsibility for publication of the results of this 
study.  The study results will be submitted for publication in a peer-reviewed journal 
within 24 months of the end of data collection, regardless of the outcomes. 

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16. REFERENCES  
 
1. Ahmed M, Brace CL, Lee FT, Goldberg SN.  Principles of and advances in 
percutaneous ablation.  Radiology 2011; 258:351-369. 
2. Sainani NI, Shyn PB, Tatli S, Morrison PR, Tuncali K, Silverman SG. 
PET/CT-guided radiofrequency and cryoablation: Is tumor Fluorine-18 
fluorodeoxyglucose activity dissipated by thermal ablation? J 
VascIntervRadiol 2011;22:354-360 
 
3. Shyn PB, Tatli S, Sainani NI, Morrison PR, Habbab F, Catalano P, Silverman SG.  
Minimizing image misregistration during PET/CT-guided percutaneous interventions 
using monitored breath-hold PET and CT acquisitions.  J VascIntervRadiol 
2011;22(9):1287-92 
4. Tatli S, Gerbaudo VH, Feeley CM, Shyn PB, Tuncali K, Silverman SG. 
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17. APPENDICES 
 

FDG PET/CT-Guided Liver Tumor Ablation: Intraprocedural Assessment of Results Using 
Ammonia Perfusion PET 
6/9/2014 
 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
36 
 

Perfusion PET Assessment of Liver Tumor Ablations 
 
 
 
 
Version 6/9/2014  
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
37 
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-
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.