Pilot Trial of PET Imaging With 89Zr-DFO-Trastuzumab in Esophagogastric Cancer
Phase: NA
Conditions: Esophagogastric Cancer
Sponsor: Memorial Sloan Kettering Cancer Center

 
  
 
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MSK PROTOCOL COVER SHEET 
Pilot Trial of PET Imaging with 89Zr-DFO-trastuzumab in Esophagogastric Cancer 
Neeta Pandit-Taskar, MD/Radiology  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table of Contents 
Memorial Sloan Kettering Cancer Center
IRB Number: 13-165 A(12)
Approval date: 30-Nov-2020

 
  
 
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1.0 
PROTOCOL SUMMARY AND/OR SCHEMA ..................................................................... 3 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS .............................................................................. 5 
2.1 
Primary Objectives ......................................................................................................... 5 
2.2 
Secondary Objectives .................................................................................................... 6 
3.0 
BACKGROUND AND RATIONALE .................................................................................... 6 
3.1 
The Problem Being Addressed: ....................................................................................... 6 
3.2 
Positron Emission Tomography (PET) ........................................................................ 9 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ......................................................... 13 
4.1 
Design ............................................................................................................................. 13 
4.2 
Intervention ..................................................................................................................... 14 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS.......................................................................... 15 
Package Labeling and Formulation ....................................................................................... 16 
5. 1 
Dose Adjustments........................................................................................................... 17 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY.......................................................................... 17 
6.1 
Subject Inclusion Criteria ................................................................................................ 17 
6.2 
Subject Exclusion Criteria............................................................................................... 18 
7.0 
RECRUITMENT PLAN ...................................................................................................... 18 
8.0 
PRETREATMENT EVALUATION ..................................................................................... 19 
9.0 
TREATMENT/INTERVENTION PLAN .............................................................................. 20 
9.1  
Pharmacokinetics ......................................................................................................... 20 
9.2 
Imaging .......................................................................................................................... 20 
9.3 
Whole body probe measurements (Cohort 1) ........................................................... 21 
9.4 
Assessment for Toxicity .............................................................................................. 22 
10.0 EVALUATION DURING TREATMENT/INTERVENTION ................................................. 23 
Laboratory Safety Assessments ............................................................................................ 23 
Performance Status ............................................................................................................... 23 
Vital Signs............................................................................................................................... 23 
11.0 TOXICITIES/SIDE EFFECTS ............................................................................................ 26 
Table 2 .......................................................................................................................................... 27 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT ................... 28 
12.1 CT and MRI .................................................................................................................... 29 
13.0 CRITERIA FOR REMOVAL FROM STUDY ..................................................................... 29 
14.0 BIOSTATISTICS ................................................................................................................ 29 
14.1 Primary Objective ......................................................................................................... 29 
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IRB Number: 13-165 A(12)
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15.0  RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES32 
15.1 Research Participant Registration.................................................................................. 32 
15.2 Randomization ................................................................................................................ 32 
16.0 DATA MANAGEMENT ISSUES........................................................................................ 32 
16.1 Quality Assurance........................................................................................................... 33 
16.2 Data and Safety Monitoring ............................................................................................ 33 
17.0 PROTECTION OF HUMAN SUBJECTS........................................................................... 34 
17.1 Privacy ............................................................................................................................ 34 
17.2 Serious Adverse Event (SAE) Reporting ....................................................................... 35 
17.2.1...................................................................................................................................... 36 
18.0 INFORMED CONSENT PROCEDURES........................................................................... 38 
19.0 REFERENCES ................................................................................................................... 38 
20.0 APPENDICES .................................................................................................................... 43 
Karnofsky Performance Scale............................................................................................ 43 
 
 
 
 
 
 
 
 
 
 
 
 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA 
Primary Objectives:   
1)  Evaluate the safety of 89Zr-DFO-trastuzumab and the ability to detect tumors using PET 
imaging in patients with HER2  positive esophagogastric (EG) cancer 
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2)  Determine the biodistribution and pharmacokinetics in normal organs and tumor of 89Zr-DFO-
trastuzumab in patients with esophagogastric cancer, and perform dosimetry estimates based on 
the data. 
Secondary Objectives: 
1) Evaluate changes in biodistribution of 89Zr-DFO-trastuzumab in patients receiving HER2 
directed therapy.  
2) Patients who have archived tissue or will be having a clinically indicated biopsy will be asked 
to consent to have this tissue made available for molecular analysis of their tumor to 
correlate with imaging results. 
3) Evaluate imaging results with response to treatment.  
Patient Population:  
The study group will be comprised of 55 patients with primary or metastatic HER2 positive EG 
cancer with evidence of measurable or evaluable disease.  
Design:   
PET imaging studies with 89Zr-DFO-trastuzumab  will be carried out in 55 patients. All patients will 
receive 89Zr-DFO-trastuzumab radiotracer and then undergo PET scanning to determine if tumor 
localization is observed. Ten patients will undergo injection of 89Zr-DFO-trastuzumab and undergo 
serial imaging, serum sampling and whole body counts for determination of biodistribution, 
dosimetry, pharmacokinetics and identification of optimal imaging time. The patients will be asked to 
consent to provide molecular analysis data obtained from archived tissue from their tumors, which 
will be correlated with89Zr-DFO-trastuzumab imaging results once funding is available. No molecular 
analysis or tissue procurement will be done under this protocol. In both cohorts (up to 55 patients), 
those receiving HER2 directed therapy (e.g. trastuzumab, afatinib or lapatinib), will receive up to two 
injections of 89Zr-DFO-trastuzumab, prior to commencing treatment and within 6 weeks of  start of 
HER2 directed therapy. The second injection will require a single timepoint scan.  
Treatment Plan:   
For each PET study: patients will receive 5 mCi + 0.5 mCi of 89Zr-DFO-trastuzumab given IV over 5-
10 min. Because of well described, dose dependent pharmacokinetics in the literature, injection of 
cold trastuzumab will be mixed with 89Zr-DFO-trastuzumab so that total mass is equal to 50 mg [1]. 
In the first ten patients we wish to obtain normal organ dosimetry, pharmacokinetics and determine 
optimal imaging time, therefore these patients will undergo imaging at 4 time points post injection, 
whole body counts and blood draws. Subsequent patients will receive the antibody and will only 
undergo imaging at a single time point (based on the first 10 patients) and will not have whole body 
counts or serial bloods for pharmacokinetics.   The administration of 89Zr-DFO-trastuzumab to 
patients undergoing a second study will be identical as for their baseline study. Patients undergoing 
a second injection will only have one scan that will be performed within 1 day before or 2 days after 
their optimum imaging time point, determined from their baseline imaging study.  
Duration of Study:   
Accrual to this study should be complete in 24 months. 
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Regulatory Issues:   
89Zr-DFO-trastuzumab PET studies will be performed under the auspices of an IND (US FDA), no 
studies will be performed until the IND is obtained. No patient management decisions will be made 
based on these imaging studies. 
Protocol schema:     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Timing of repeat study will depend on treatment being administered and will be selected in  
conjunction with the treating PI based on what is thought to be most appropriate.  
 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS 
2.1 
Primary Objectives 
 
Evaluate the safety of 89Zr-DFO-trastuzumab and the ability to detect tumors 
using PET imaging in patients with HER2  positive esophagogastric (EG) cancer  
 
Determine the biodistribution and pharmacokinetics in normal organs and tumor 
of 89Zr-DFO-trastuzumab in patients with esophagogastric cancer, and perform 
dosimetry estimates based on data 
HER2-positive esophagogastric cancer  
Cohort 1:   
10 patients will be enrolled to receive a single 50 
mg dose of the 89Zr-DFO-trastuzumab/ 
trastuzumab. 
They will undergo serial imaging, whole body 
counts and pharmacokinetics. 
Patients receiving therapies directed at HER2, will 
be offered repeat imaging study at a single time 
point 2 to 6  weeks post start of treatment to 
evaluate for changes in tumor uptake. 
Cohort 2:    
45 patients will be enrolled to receive a single 50mg 
dose of the Single imaging at optimal imaging time 
point decided 89Zr-DFO-trastuzumab/trastuzumab 
based on cohort 1 and no pharmacokinetics or whole 
body counts 
Patients receiving therapies directed at HER2, will be 
offered repeat imaging study at a single time point 2 to 
6 weeks post treatment to evaluate for changes in 
tumor uptake, the exact timing will be fixed depending 
on the type of therapy patient will receive.  
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IRB Number: 13-165 A(12)
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2.2 
Secondary Objectives 
 
Evaluate changes in biodistribution of 89Zr-DFO-trastuzumab in patients receiving 
HER2 directed therapy.  
 
Patients who have archived tissue or will be having a clinically indicated biopsy 
will be asked to consent to have this tissue made available for molecular analysis 
of their tumor to correlate with imaging results. 
 
Evaluate imaging results with response to treatment.  
 
3.0 
BACKGROUND AND RATIONALE 
INTRODUCTION 
The HER2 receptor is a 185-kDa transmembrane receptor tyrosine kinase that is expressed 
in a wide variety of human epithelial cancers including breast, bladder, ovarian, endometrial, 
cervical, lung, stomach, prostate as well as head and neck and pancreatic cancers [2]. In 
preclinical studies, HER2 over-expression has been found to contribute to oncogenic 
transformation, tumorigenesis, and metastatic potential [3, 4]. In human breast cancers, 
HER2 is overexpressed in 20-30% of cases, and this has been correlated with resistance to 
therapy, shorter disease-free and overall survival in patients with this disease [5, 6]. The 
ErbB2/HER2 oncogene encodes a transmembrane tyrosine kinase receptor that belongs to 
the epidermal growth factor receptor (EGFR) family and plays an essential role in promoting 
cell growth, migration, differentiation, proliferation, and survival. The family is comprised of 
ErbB1 (EGFR/HER1), ErbB2 (HER2/neu), ErbB3 (HER3), and ErbB4 (HER4). Each receptor 
has an extracellular domain, a lipophilic transmembrane domain, and an intracellular tyrosine 
kinase domain. Activation of the kinase occurs with ligand binding and hetero- or 
homodimerization of these receptors. Ligand-independent activation of HER2 may occur due 
to mutations in HER2 or receptor overexpression [7]. Activation plays a pivotal role in cell 
proliferation and survival which has been shown to be mediated largely through activation of 
the phosphatidylinositol 3’-kinase-AKT-mammalian target of rapamycin (PI3K-AKT-mTOR) 
pathway[8]. Hence HER2 has become a very important target of anticancer drug 
development.    
Trastuzumab, a humanized anti-HER2 monoclonal antibody (Herceptin; Genentech, South 
San Francisco, CA), inhibits the growth of breast cancer cells with HER2 over-expression [9]. 
In a landmark randomized clinical trial, the addition of trastuzumab to chemotherapy 
improved response rates and prolonged survival for patients with HER2-overexpressing 
metastatic breast cancer [10]. Four separate, large, multicenter randomized adjuvant trials 
have shown a 50% reduction in the risk of recurrence for women with HER2+ early stage 
breast cancer treated with trastuzumab plus chemotherapy versus chemotherapy alone [11, 
12]. In spite of these remarkable results, trastuzumab has activity in only a minority of breast 
cancer patients with HER2 over-expression, with response rates for trastuzumab 
monotherapy in the range of 12- 26% [13-15]. Moreover, resistance to trastuzumab 
eventually develops in the majority of cases. 
3.1 
The Problem Being Addressed: 
3.1.1 Esophagogastric adenocarcinoma  
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World-wide, esophagogastric cancer is diagnosed in nearly one million individuals each year 
and is the second most common cause of cancer-related death [16, 17]. Most patients with 
esophagogastric cancer present with stage IV disease, which is incurable. Despite this, 
systemic chemotherapy can lead to a decrease in cancer-related symptoms and prolongs 
survival [11, 18-20]. However, even with treatment, most patients with advanced gastric 
cancer have a median survival of less than 1 year. More specific molecularly targeted 
therapies are anticipated to improve the current status of systemic treatment beyond 
conventional cytotoxic therapy.  
3.1.2 Human Epidermal Growth Factor Receptor (HER2) in esophagogastric 
adenocarcinoma  
HER2 is a validated treatment target in esophagogastric cancer, based on results of the 
trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of 
HER2-positive advanced gastric or gastro-esophageal junction cancer (ToGA): a phase III, 
open-label, randomized controlled trial demonstrating improved response and survival when 
trastuzumab is added to chemotherapy. Approximately 30% of stomach card 
ia/gastroesophageal junction (GE junction) tumors harbor HER2 gene amplification 
(assessed by fluorescent in situ hybridization [FISH] and/or HER2 oncoprotein 
overexpression (assessed by immunohistochemistry [IHC]) [21-23]. The rise in the incidence 
of gastroesophageal junction tumors in western countries [24, 25] underscores the 
significance of this new target in esophagogastric cancer, and opens a new drug 
development strategy for this disease. 
There is limited data on the heterogeneity of expression of HER2 in gastric cancer between 
primary and metastatic sites [26]. In one report a discrepancy between primary and 
metastatic lesions was seen in 2 of 60 cases [27], with discrepancy seen between different 
tumor blocks. There is some data that suggest heterogeneity between primary and 
metastatic lesion in breast cancer [28]. There have been report of discrepancy between FISH 
and protein expression, this may allow imaging to more effectively select patients who are 
better candidates for trastuzumab therapy.  
3.1.3 ToGA study: trastuzumab in HER2-positive esophagogastric adenocarcinoma  
With the results of the phase III ToGA study, the benefit of trastuzumab in combination with 
cisplatin and fluoropyrimidine (CF) chemotherapy in HER2-positive metastatic 
esophagogastric adenocarcinoma has been established [29]. This study comprised 584 
patients with HER2-positive gastric or GE junction tumors. Patients were randomly assigned 
to receive cisplatin and capecitabine (fluorouracil infusion was given to patients who were 
unable to take oral medication) alone or with trastuzumab. Patients assigned to receive 
trastuzumab with chemotherapy had a significant improvement in all measures of efficacy 
including overall survival, progression-free survival, and overall response rate (CR+PR). 
Notably, patients with strongly HER2-positive tumors (IHC 2+/FISH+ or IHC3+) derived the 
greatest overall survival benefit with the addition of trastuzumab to chemotherapy [29]. The 
selection of high HER2 expressing patients may be a setting in which quantitative imaging 
with 89Zr-DFO-trastuzumab may provide prognostic information for patient selection to HER2 
directed therapy. 
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Trastuzumab is the first biological strategy to show a survival benefit in advanced 
esophagogastric adenocarcinoma. Trastuzumab is now approved by the FDA and European 
Union (EMA) for treatment of patients with HER2-positive advanced gastric cancer in 
combination with systemic chemotherapy.  
3.1.4 Trastuzumab: mechanism of action and the emergence of resistance  
Trastuzumab is approved by the FDA and is the standard of care for patients with HER2-
positive advanced gastric cancer in combination with systemic chemotherapy.  Resistance to 
trastuzumab is now emerging in HER2-positive esophagogastric cancer.  There is no 
standard of care treatment at this time that has been shown to reliably induce a second 
response in these patients.   
Whereas anti-HER2 therapy with trastuzumab has shown efficacy in some HER2-positive 
esophagogastric cancer, limitations to this approach can include coincident activation of 
downstream signaling pathways. In HER2-positive breast cancer, both de novo and acquired 
resistance to trastuzumab are now recognized [30]. Elucidating the molecular mechanisms of 
trastuzumab resistance will aid in the development of new targeted therapies and a number 
of putative models of resistance have been described in HER2-positive breast cancer [14]. In 
breast cancer, one of the best-characterized mechanisms of trastuzumab resistance involves 
increased signaling from other EGFR members of EGFR family of receptors. Other 
mechanism  of resistance is the accumulation of a truncated form of HER2 (p95-HER2) 
which lacks the extracellular domain needed for trastuzumab binding. This truncated receptor 
maintains kinase activity independent of ligand binding and is able to activate downstream 
signaling pathways [31]. By imaging with 89Zr-DFO-trastuzumab we may be able to detect 
patients who lack the extracellular domain of HER2, since they are expected to have a 
negative scan.  
Activation of PI3K-AKT-mTOR pathway by two genetic mechanisms, loss of the PTEN tumor 
suppressor and mutational activation of PI3K, has been demonstrated to confer resistance to 
trastuzumab in animal models and a small series of clinical tumor samples in breast cancer 
[32]. Increased insulin-like growth factor-1 receptor (IGF-1R) signaling is also associated with 
PI3K-AKT activation and trastuzumab resistance [33, 34]. In gastric cancer tumors, IGF-1R is 
most commonly overexpressed in HER2-positive tumors and correlates with poor prognosis 
and increased propensity to metastasize [12, 35, 36].  Through a better understanding of 
these models of resistance, new targeted therapies will be developed to improve response 
rates in HER2-positive esophagogastric cancer patients.  
3.1.5 EGFR/HER2 Tyrosine Kinase Inhibitors (TKIs) 
A series of TKI’s of HER 2 are being developed. Lapatinib is a reversible tyrosine kinase 
inhibitor of EGFR and HER2 that blocks receptor activation by binding to the intracellular 
ATP binding site of these kinases. It has shown some effect in HER2 positive breast cancer 
patients [37, 38]. In a number of studies of single agent lapatinib in esophagogastric 
adenocarcinomas, modest activity has been documented [39]. 
Lapatinib is currently being tested in two phase III trials in gastric cancer. TYTAN is an open-
label, randomized phase III study comparing paclitaxel with paclitaxel plus lapatinib in 
patients with HER2 FISH-amplified gastric cancer as a second-line therapy.  
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In vitro data suggest that second-generation irreversible inhibitors covalently bind HER2 and 
EGFR (unlike lapatinib, which compete with ATP in a reversible manner) in a highly selective 
fashion may be able to overcome trastuzumab resistance.  
Afatinib (BIBW 2992) is a highly selective and potent low molecular weight, irreversible 
inhibitor of the erbB-family tyrosine kinase receptors EGFR, HER2 and HER4. MSK 
preclinical data shows potent antitumor activity of single agent afatinib in HER2-positive 
esophagogastric cancer xenografts (Janjigian 2011 unpublished data and is the basis for an 
ongoing MSKCC protocol 11-166.).  
3.2 
Positron Emission Tomography (PET) 
PET has advantages over conventional imaging methods because it quantitatively assesses 
biologic processes in vivo and can assess molecular based pathways using specific 
radiotracers. Processes that can be analyzed with currently available reagents include 
glycolysis, amino acid metabolism, proliferation, blood flow, and receptor status (i.e., 
androgen receptor). Most clinical  studies have focused on the accumulation of FDG. 
 
A large amount of work has been performed using radiolabeled monoclonal antibodies with 
single photon emitters such as I-131, I-123, Tc-99m and In-111. In contrast to single photon 
emitters, positron emitters have advantages over conventional imaging methods because it 
quantitatively assesses biologic processes in vivo, furthermore PET scanner have higher 
sensitivity and resolution that conventional scanner for single photon emitters and are 
quantitative.   
Various imaging studies have been performed with positron labeled antibodies. Our group 
has been a pioneer in the use of both I-124 and 89Zr-labeled MAb. We have shown the 
excellent imaging characteristics of I-124 cG250 in patients with clear cell renal cancer [40]. 
In that study there was a sensitivity of 90% and specificity of 100%.  This has led to a Phase 
3 multicenter trial with intent to seek FDA approval for imaging of renal cell cancer.  In a 
separate trial we have reported the targeting, imaging and pharmacokinetic characteristics of 
I-124 A33 monoclonal antibody in colorectal cancer patients [41].  In the latter 2 reports these 
antibodies are not highly internalizing and thus I-124, a non residualizing label is adequate 
for imaging.   
We have previously evaluated different Positron emitting versions of trastuzumab antibodies, 
one labeled with Ga-68 and the other with Cu-64 in 2 clinical trials at MSKCC. In prior animal 
studies, we have used Ga-68 DOTA F(ab)’2 trastuzumab for monitoring HER2 inhibition with 
HSP90 inhibitors, as a basis for non-invasive imaging of pharmacodynamics of drug action 
[42, 43]. Our initials studies using Cu-64 DOTA trastuzumab demonstrated the safety and 
tolerability of this reagent in 11 patients.  Furthermore, those studies showed that tumor 
localization could be observed in selected patients receiving large doses of trastuzumab 
although sensitivity was limited (personal observation, data not published). The 
pharmacokinetics of the intact Cu-64 DOTA-trastuzumab showed a biologic half-life of 
approximately 3 days and a mean of ~81% was present in the plasma 24 h after tracer 
administration. Our current proposal will allow in vivo tracing of the pharmacokinetic behavior 
of the intact 89Zr-DFO-trastuzumab antibody. The PET images will allow us to see the 
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distribution of trastuzumab into different tissues and organs as well as tumor sites. The 
longer T1/2 of 89Zr of 78 h is more suitable for the pharmacokinetics of the antibody at the 
required 50 mg dose. This information may serve as a basis for understanding the 
mechanisms of action and resistance, and toxicities associated with trastuzumab and HER2 
directed therapies, and would form the basis for predicting the pharmacokinetics of 
trastuzumab-based conjugate therapies, which are emerging as potential therapeutic agents 
for HER2-positive disease, selection of patients and evaluation of treatment response.  
Clinical use 89Zr  labeled antibodies, including their  successful use in patients with breast 
cancer and head and neck has been reported [1, 44]. Furthermore, in an our own ongoing 
trial with 89-Zr-DFO-J591 excellent targeting has been observed.   
 
 
3.2.1 
89Zirconium 
89Zr is an attractive metallo-radionuclide for use in immuno-PET due to favorable decay 
characteristics. It has a 78.4h half life and a 22.7% positron yield.  
Standardized methods for the routine production and isolation of high-purity and high-
specific-activity 89Zr using a small cyclotron are reported. Optimized cyclotron conditions 
reveal high average yields of 1.52 ± 0.11 mCi/muA*h at a proton beam energy of 15 MeV 
and current of 15 muA using a solid, commercially available 89Y-foil target (0.1 mm, 100% 
natural abundance). The effective specific activity of 89Zr was found to be in the range of 
5.2813.43 mCi/microg (4701195 Ci/mmol) of zirconium.  
Radiolabeling studies using the trihydroxamate ligand desferrioxamine B (DFO) gave 100% 
radiochemical yields in <15 min at room temperature, and in vitro stability measurements 
confirmed that (89Zr) Zr-DFO is stable with respect to ligand dissociation in human serum for 
>7 days. Small-animal show that  89Zr chloride and 89Zr -oxalate reached 15- 20% of injected 
dose in bone  after 6 days whereas 89Zr-phosphate was only 5% of ID in bone but high 
amounts in the liver and the spleen [45].  
These results have important implications for the analysis of immuno-PET imaging of 89Zr-
DFO labeled monoclonal antibodies. The detailed methods described can be easily 
translated to other radiochemistry facilities and will facilitate the use of 89Zr in both basic 
science and clinical investigations [46-48].  
3.2.2 Pharmacokinetics and biodistribution of chimeric or humanized monoclonal 
antibodies. 
We have based our antibody mass dose selection on previous dose seeking clinical studies 
using radiolabeled trastuzumab [1]. Furthermore we have drawn on the experience with 
various other antibodies to select our initial mass of 89Zr-DFO-trastuzumab. The 
pharmacokinetics of a variety of radiolabeled antibodies has been determined in humans. 
Some antibodies have cross reactivity with normal antigens in vivo and thus require a certain 
mass amount in order to optimize pharmacokinetics and biodistribution. As an example 
clinical trials with 89Zr-DFO-trastuzumab have shown that mass of about 50 mg is necessary 
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in trastuzumab naïve patients. Other reports using Cu-64 labeled trastuzumab have shown 
that doses much smaller than 50 mg resulted in poor biodistribution [49].  Studies in patients 
with lymphoma targeting CD20 with In-111 Ibritumomab (2B8) showed that in 6 of 10 
patients more lesions were identified with 1mg/kg co-infusion than with 2 mg total of antibody 
[50].   A clinical trial using In-111 hPAM4  showed good targeting and similar 
pharmacokinetics of doses ranging from < 10 mg compared to 100 mg [51] with T1/2 of 
91.2h.  In contrast, studies with the chimeric 89Zr-cmAb U36 found adequate targeting when 
using 10 mg of the IgG. We have utilized PET imaging of I-124 anti-huA33 antibody to target 
A33 antigen, a transmembrane glycoprotein with homology to tight junction-associated 
proteins that is present in normal colon and small bowel epithelium as well as in over 95% of 
human colon adenocarcinoma and approximately 50% of gastric and  pancreatic cancers, 
while absent in most other human tissues and tumors [52]. Our studies utilizing 10 mg of  I-
124 A33 have shown excellent targeting and have demonstrated Vd close to that of plasma 
3,257 +  631 mL, T1/2 of ~ 65 h and Co of ~31.9%ID/L [41]. In our experience the use of 10 
mg of I-124 chimeric antibody cG250 resulted in excellent imaging of renal cell tumors [40]. 
The pharmacokinetic analysis in a clinical trial that used 2, 5, 10, 25 and 50 mg of I-131 
cG250 showed that at the 2 mg dose levels there was faster clearance but at all other levels 
there was no dose response with a median T1/2 of 68.5 h. When doses of 25 and 50 mg of 
cG250 were  administered there was less tumor uptake than at the 10 mg dose [53]. 
Humanized antibody hPAM4 specifically binds a mucin glycoprotein expressed in pancreatic 
adenocarcinomas.  
3.2.3 
Rationale for 89Zr-DFO-trastuzumab   PET use in Esophagogastric cancer  
Various radionuclides are available to label monoclonal antibody for imaging, 
pharmacokinetics and biodistribution. Antibodies labeled with positron emitters have 
significant advantage compared to single photon emitters. These include the higher 
sensitivity, spatial resolution of PET and its quantitative ability. At MSKCC we have used 
various positron emitters for labeling antibodies. It is well known that for antibodies that 
internalize there is significant improved tumor retention of radiometals compared to Iodinated 
antibodies [54]. 89Zr has an ideal half-life (78h) that is well matched to the half life of intact 
IgG in the intravascular compartment, that in the case of trastuzumab varies from 2 to 12 
days at a 10 and 500 mg dose level. Determining if 89Zr-DFO-trastuzumab   PET can predict 
presence of HER2 may also allow to quantitate HER2 antigen expression and perhaps allow 
one to rationally select patients that are more likely to respond to HER2 directed therapies. 
Furthermore, if high sensitivity for tumor detection is observed 89Zr-DFO-trastuzumab PET 
may allow for staging of extent of disease.  
The first in-human 89Zr-DFO-trastuzumab PET in breast cancer showed excellent 
visualization and uptake in HER2-positive tumors.[1]  
89Zr-DFO-trastuzumab PET has a potential advantage over single site biopsies as it can non-
invasively assess target engagement and inhibition reflecting the functional effects of HER2-
targeted agents in the primary tumor and all sites of metastases simultaneously [55, 56]. In 
HER2-positive EG cancer, heterogeneity of HER2 expression within primary tumors and 
metastasis is a particular challenge and may contribute to trastuzumab resistance. Moreover, 
the biodistribution of trastuzumab varies in each patient and is heavily impacted by the extent 
of tumor load, which may contribute to variations in patient responses [57]. 89Zr-DFO-
trastuzumab PET can thus help elucidate the molecular basis of resistance to trastuzumab in 
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Figure 1. Imaging the effects of afatinib therapy with 89Zr-DFO-trastuzumab PET. A. 89Zr-DFO-
trastuzumab PET images of control (left) and afatinib (right) treated mice bearing s.c. NCI-N87 tumors. 
B. Bar charts showing regions-of- interest (%ID tumor uptake) for 89Zr-DFO-trastuzumab and  FDG 
uptake recorded and tumor weight ( at baseline, 7, 14 days post afatinib. Insert demonstrates PD studies 
on HER2 by immunoblot .  
EG cancer and facilitate the development of an optimal dose and schedule of HER2 targeted 
agents tailored to individual patient’s tumor burden and biology. Decrease in FDG-PET 
uptake of greater than 30% from baseline is a validated predictor of tumor response and 
survival with chemotherapy in EG cancer patients [58-60]. However, a proportion of EG 
cancers are not FDG-PET avid [61], thus 89Zr-DFO-trastuzumab   may provide a method to 
asses response. 89Zr-DFO-trastuzumab PET showed excellent tumor visualization in patients 
with HER2-positive breast cancer [1, 62]. MSKCC data demonstrates that 89Zr-DFO-
trastuzumab PET can image the tumor response and PD changes in HER2-positive EG 
xenografts treated with afatinib (Fig 1), while the changes are not visualized with FDG-PET.  
 
 
 
Currently IHC is used to determine HER2 status and select candidates for HER 2 directed 
therapy. If this pilot trial is successful new this technology may have an impact on various 
aspects of managing patients with esophagogastric cancers.  For example 89Zr-DFO-
Trastuzumab may be incorporated into routine clinical practice for staging, diagnosis and 
monitoring treatment response in patients with HER2-positive tumors. 89Zr-DFO-
Trastuzumab may be used to aid in treatment planning by non- invasively selecting 
candidates for HER2-directed therapy.  Whereas, IHC is a qualitative method limited  to the 
biopsied site, if successful 89Zr-DFO-Trastuzumab PET imaging will be implemented as a 
quantitative method to assess the primary tumor and all sites of metastatic disease providing 
the  index of HER2 density.  Currently patients are treated with HER2 directed therapies and 
assessed after a period of treatment for evidence of response by size change criteria.  This 
method may facilitate early predictor of tumor response than decrease in tumor size on CT. 
3.2.4 Tissue correlates with PET antibody imaging  
We have documented with interventional radiology directed biopsies that sensitivity of tumor 
detection is greater than CT, PET-FDG or bone scanning using 89Zr-DFO-J591 (unpublished 
data). Further studies are ongoing with image directed biopsy. The correlation of molecular 
characteristics, tissue histology and antibody imaging may give insight into mechanism of 
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Page 13 of 44 
 
uptake. We will use banked tissue  for correlation of proteonomics or genomics with imaging 
results in a pilot fashion. We will not perform biopsies under the auspices of this protocol.  
 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
4.1 
Design 
This is a single institution, open-label, non-randomized, pilot evaluation of 89Zr-DFO-
trastuzumab PET imaging in patients with HER2-positive esophagogastric cancer. Patients 
will receive up to 5 mCi of 89Zr-DFO-trastuzumab (initial 5 patients will receive 5 mCi, the 
activity may be adjusted downward if technically feasible). In order to optimize tumor 
targeting the activity of 89Zr-DFO-trastuzumab will be brought up to a final 50mg dose by 
adding non-conjugated trastuzumab (example 5 mCi/3mg DFO-trastuzumab  + 47 mg of 
trastuzumab). Data in the literature, in breast cancer patients, has shown that the optimal 
mass of trastuzumab is ~50 mg, in patients with no trastuzumab on board [1]. During the 
biodistribution, pharmacokinetics and optimization phase, 10 patients will undergo 4 serial 
PET scans for dosimetry and determination of optimal imaging time and scan parameters. 
The optimal time for imaging is probably 3 to 8 days, as has been observed with other intact 
IgG antibodies. In order to confirm these findings with our own preparation of 89Zr-DFO-
trastuzumab we will do pharmacokinetics and serial imaging in the first 10 patients enrolled. 
After the first 10 patients, all other patients will be injected with the tracer and imaged at the 
optimum time, selected based on the initial 10 patients and no pharmacokinetics will be 
performed.   
Patients that will start a therapeutic regimen mediated through HER2 will be asked to have 
an additional 89Zr-DFO-trastuzumab scan. If patient agree they will have a baseline study 
prior to start of therapy and if positive localization is observed they will have  a optional 
second 89Zr-DFO-trastuzumab repeated while on therapy following at least one cycle of 
therapy, or at a time point that the PI and CO-Pi’s consider appropriate. At least 2 weeks will 
have elapsed between baseline and second injection to allow for decay and no more than 6 
weeks. The second study will also be done using up to 5 mCi/ combined  50 mg of 89Zr-DFO-
trastuzumab and when feasible imaging will be performed on the same day post injection as 
on the baseline study or within ~1d prior or 2 days post optimal baseline imaging. In patients 
in cohort 1 (before selection of optimal imaging time) the study will be performed with ~1 to 2 
days of best imaging on their baseline study.  Images from both studies will be compared to 
determine similarities in biodistribution (concentration of activity in normal organs and tumor).  
Baseline testing will be performed prior to injections with 89Zr-DFO-trastuzumab. This 
includes history, hematology, chemistry, urinalysis, negative serum pregnancy test for female 
of child bearing potential, vital signs, ECG and baseline serum sample will be collected for 
possible analysis of complex formation if altered pharmacokinetics are observed and banked 
for testing of immune response to the DFO-trastuzumab. Patients will be assessed for 
toxicity.  
Because 89Zr-DFO-trastuzumab  has only been evaluated in a small number of patients, and 
since no studies have been performed in the USA, toxicity assessment will be performed 
using Common Terminology Criteria for Adverse Events (CTCAE) v4. 
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Page 14 of 44 
 
4.2 
Intervention 
The intervention is the administration of a single dose of 89Zr-DFO-trastuzumab tracer for 
imaging purposes. Patients will be approached by their oncologists for informed consent and 
enrollment  to the study during their regularly scheduled follow-up appointments at MSK 
outpatient facilities or referred to Molecular Imaging Investigators for obtaining informed 
consent. The day of the study the patient will report to the Molecular Imaging and Therapy 
Service at the  Main Campus. For the first 10 patients,   two intravenous catheters will be 
inserted whenever feasible to allow for separate site for injection and blood draw for 
pharmacokinetics. For others who will receive scanning only, one IV will be inserted. The 
89Zr-DFO-trastuzumab tracer dose will be combined with non-radiolabeled trastuzumab for a 
total of 50 mg trastuzumab will be injected IV over 5-10 min using an in-line (0.22 micron) 
filter, followed by a flush of ~10 ml of normal saline. The infusion will be carried out under the 
supervision of the Principal Investigator (PI) or an authorized user assigned by the PI. The 
syringe will be measured for 89Zr radioactivity prior to and at the end of infusion, and the net 
amounts of radioactivity will be recorded, along with the time of measurement, and the net 
amount of radioactivity administered calculated.   
Patients undergoing serial imaging will have whole body count measurements using a NaI 
probe, placed at ~3.3 yards from the patient, to determine whole body retention: after 
antibody infusion, prior to voiding and post void, as well as at each time of return for imaging.  
Imaging for the initial group undergoing serial scans will start within 1-4 hr of end of the 89Zr-
DFO-trastuzumab infusion, ~24h, ~48-96h and ~120-192h post injection. The administration 
of 89Zr-DFO-trastuzumab to patients undergoing a second study will be identical as for their 
baseline study. Patients undergoing a second injection will only have one scan that will be 
performed within 1 day before or 2 days after their optimum imaging time point, determined 
from their baseline imaging study. 
Pharmacokinetic blood sampling will be performed utilizing a separate IV site (if feasible). 
Blood samples for 89Zr-DFO-trastuzumab levels will be drawn prior to the 89Zr-DFO-
trastuzumab injection and at approximately 5 ± 2, 15 ± 5, 30 ± 9, 60 ± 19, and 120 to 240 
minutes and a sample at the time of each subsequent day of imaging (~24h, ~48-96h and 
~120-192h) post injection these are ideal times and after the first day a window of ± 8h will 
be allowed. In all patients on the day of first infusion and prior to 89Zr-DFO-trastuzumab 
injection baseline blood will banked for determination of complexes formation with 89Zr-DFO-
trastuzumab.  
 
 
 
 
Intervention schema 
 
Eligible patients with esophagogastric 
cancer will be registered to study 
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5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS 
 
The Investigational New Drug in this study is 89Zr-DFO-trastuzumab. Trastuzumab is a 
humanized antibody that targets HER2 approved for the treatment of HER2+ metastatic 
gastric cancer. We will use 89Zr, a positron-emitting radionuclide, labeled to trastuzumab via 
DFO. For 89Zr labeling DFO will be attached to trastuzumab. To bring the total mass to 50 mg 
of antibody, trastuzumab kits will be reconstituted as per manufacture instructions by 
Cohort 2: 45 patients will receive a single, up to 
5 mCi, 50 mg dose of the 89Zr DFO-trastuzumab 
1) PET CT images  
1-4 h 
 ~24h 
~48-96h  
 ~120-192h post injection 
2) Pharmacokinetics 
Baseline, 5 ± 2, 15 ± 5, 30 ± 9, 60 ± 19, and 
120 to 240 minutes  
~24h 
~48-96h  
 ~120-192h post injection 
3) Whole Body probe counts  
Pre and post void first day. 
 ~24h 
~48-96h  
 ~120-192h post injection 
4)  Assessment for toxicity during each visit 
and 8-14 days after injection 
Cohort 1: 10 patients will receive a single, up 
to 5 mCi, 50 mg dose of the 89Zr DFO-
trastuzumab 
1) PET CT images 1 time, at optimal time that 
will be determined based on cohort 1 
2) Assessment for toxicity during imaging visit 
and 8-14 days after injection 
Up to 30 patients will have optional 
repeat injection of  up to 5 mCi, 50 
mg dose of the 89Zr DFO-
trastuzumab 
1) PET CT images 1 time point 
only, at same date -1d/+2d  
based on patients baseline 
study 
2) Assessment for toxicity during 
imaging visit and 8-14 days 
after injection 
Optional for patients 
w ho will undergo 
HER2 directed 
therapies 
Optional for patients 
w ho will undergo 
HER2 directed 
therapies 
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Approval date: 30-Nov-2020

 
  
 
Page 16 of 44 
 
MSKCC pharmacy and sufficient amount will be added to bring the combined total of 
radiolabeled plus cold to 50 mg at the time of radiolabeling compounding.  
Drug Accountability 
The investigator is obliged to keep sufficient documentation of the delivery and  use  of the 
investigational product. The documentation will include administration date/ time, calibration 
date/time, quantity, patient name, lot number. Destruction of non used doses will be by decay 
in storage. The investigator should maintain records that document adequately that the 
patients were provided the dose specified in the protocol and reconcile the medication 
received for the study. The label of each syringe/vial will contain the patient name and lot 
number, patient and radiopharmaceutical information will be entered in the radiopharmacy 
drug accountability forms. The investigator may assign some or all of the investigator’s duties 
for drug accountability to an appropriate individual such as pharmacist, research assistant or  
Molecular Imaging and Therapy Technologist who is under the supervision of the 
investigator. 
89Zr-DFO-trastuzumab     
Radiolabeling of 89Zr-DFO-trastuzumab: The 89Zr-DFO-trastuzumab will be labeled in 
accordance with the MSKCC investigator sponsored IND. The study will be performed under 
an FDA approved IND for 89Zr-DFO-trastuzumab, no studies will be performed until the IND 
is approved. The final product will contain up to 5 mCi and will have been brought up to 
desired total  50 mg of antibody quantity by adding cold carrier trastuzumab as outlined in the 
design section. The product will have met the release criteria specified in the IND. Cold 
trastuzumab will be obtained from the MSKCC pharmacy, this antibody will be prepared in 
the standard fashion currenly made for clinical administration.  
Images will be corrected for attenuation and scatter and adjusted for system sensitivity and 
providing parametric images in terms of standardized uptake values (SUV) (= μCi found/gm 
tissue / (μCi injected/gm body mass). 
Radiochemical Purity 
The amount of free 89Zr in radiolabeled DFO-trastuzumab preparations is evaluated using 
instant thin layer chromatography. Only samples which have a radiochemical purity of >95% 
will be used for clinical studies. Release criteria in accordance with IND, must be met prior to 
use.   
Immunoreactivity 
The immunoreactivity of the radiolabeled 89Zr-DFO-trastuzumab preparation is assessed 
using Lindmo’s method [63]. The method has been validated in at least 3 immunoreactivity 
assays, to meet the criteria specified in the IND.  All radiolabeled preparations will be tested 
for immunoreactivity, though the 89Zr-DFO-trastuzumab will be administered prior to these 
results being available.   
Package Labeling and Formulation 
Each vial will contain the following information on the label:  
89Zr-DFO-trastuzumab, Solution IV  IRB xx-xxx 
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Approval date: 30-Nov-2020

 
  
 
Page 17 of 44 
 
Lot  #:______ Activity (mCi):____ Volume (mL):_____  Mass (mg): _____ 
Production Date/Time:_____ Expiration Date/Time:_____ 
Store product at room temperarute in a shieled cotainer 
Caution: New Drug Limited by Federal Law to Investigational Use. Radioactive 
Material, do not use if cloudy or contains particulate material. 
Cyclotron-Radiochemistry Core Memorial Sloan Kettering Cancer Center 
5. 1 
Dose Adjustments 
Expected dosimetry for this tracer is based on murine imaging studies: Dosimetry Table 2. 
The maximal administered dose of 5 mCi of 89Zr DFO-trastuzumab is similar in absorbed 
dose from other 89-Zr and I-124 labeled antibodies that are being used in clinical trials. The 
combined DFO-trastuzumab + trastuzumab mass will be fixed at 50 mg. 
If the analysis of the first 10 patients  undergoing serial imaging, in this study reveals an 
unexpectedly higher radiation dose  to any particular organ, a dose reduction will be 
considered. If adequate imaging statistics can be obtained with lower acivity, with acceptable 
imaging times, an activity reduction may be performed to use less than 5 mCi of activity.    
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY 
6.1 
Subject Inclusion Criteria 
To be included in this study, patients should meet all of the following criteria: 
 
Registered patient at MSKCC 
 
Age 18 years 
 
Pathologically or cytologically confirmed metastatic or primary esophagogastric 
cancer HER2 positive status by FISH or IHC as currently being implemented for 
patients with esophagogastric cancer. HER2 overexpression and/or amplification as 
determined by immunohistochemistry (3+) or FISH (≥2.0) 
 
Measurable or evaluable disease, lesions that have not been previously radiated, with 
clinically indicated imaging evaluation performed within 4 weeks prior to study entry 
(CT, MRI, FDG PET or bone scan). Patients requiring concurrent radiation treatment 
are not eligible unless additional lesions that are not being irradiated and are 
assessable for targeting are present.  
 
Karnofsky Performance Score ≥ 60 (appendix 1) 
 
Ability to understand and willingness to sign  informed consent 
 
Negative pregnancy test, to be performed on female patients of childbearing potential 
within 1week before administration of radioactive material.              
 
Life expectancy of at least three (3) months. 
 
 Willingness to use birth control while on study. 
 
The patients will be asked to consent to provide access to data obtained from 
molecular analisys that has been done on archived tumor tissue that will be 
correlated with 89Zr-DFO-trastuzumab imaging results.  
 
Concurrent therapy will be allowed. 
 
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6.2 
Subject Exclusion Criteria 
 
Inability to lie still for the duration of the scanning procedure. 
 
Patients with known sensitivity or contraindication to any of the component of 89Zr-
DFO-trastuzumab (89Zr or Desferroxiamine (DFO) or trastuzumab) 
        Patients who have received trastuzumab must have at least a washout period for 
trastuzumab of 14 days, this will not apply to 89Zr-DFO-trastuzumab repeat, post 
treatment assessment where patients may be receiving trastuzumab. 
 
HIV positive or active hepatitis. 
 
History or presence of clinically relevant cardiovascular abnormalities such as 
uncontrolled hypertension, congestive heart failure NYHA classification of 3, unstable 
angina or poorly controlled arrhythmia. Myocardial infarction within 6 months prior to 
study entry 
 
 
 
Hematologic 
o Platelets <50K/mcL 
o ANC <1.0 K/mcL  
 
Hepatic laboratory values  
o Bilirubin >2 x ULN (institutional upper limits of normal), with exception of 
patients with Gilberts disease. 
o AST/ALT >2.5 x ULN (institutional upper limits of normal); >5 x ULN if liver 
metastasis 
 
Renal laboratory values 
o Estimated GFR (eGFR) < 30mL/min/1.73m2 
7.0 
RECRUITMENT PLAN 
Recruitment Plan (with Limited Waiver of Authorization) 
Patients who meet the above inclusion and exclusion criteria will be invited to participate in the study 
by their primary oncologist. We will invite men and women, and all minorities on an equal basis.   
Consenting professionals will meet with the patients and obtain informed consent in the oncologist’s 
or Molecular Imaging and Therapy clinic. All subjects who agree to participate will be registered in 
the Office of Clinical Research. No advertisements or payments will be offered to the patients.  
Candidates must conform to all inclusion and exclusion criteria to be accepted into the study. 
If the investigator is a member of the treatment team, s/he will screen their patients’ medical records 
for suitable research study participants and discuss the study and their potential for enrolling in the 
research study. Potential subjects contacted by their treating physician will be referred to the 
investigator/ research staff of the study. 
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The principal investigator may also screen the medical records of patients with whom they do not 
have a treatment relationship for the limited purpose of identifying patients who would be eligible to 
enroll in the study and to record appropriate contact information in order to approach these patients 
regarding the possibility of enrolling in the study. 
During the initial conversation between the investigator/ research staff and the patient, the patient 
may be asked to provide certain health information that is necessary to the recruitment and 
enrollment process. The investigator/ research staff may also review portions of their medical 
records at MSKCC in order to further assess eligibility. They will use the information provided by the 
patient and/or medical record to confirm that the patient is eligible and to contact the patient 
regarding study enrollment. If the patient turns out to be ineligible for the research study, the 
research staff will destroy all information collected on the patient during the initial conversation and 
medical records review, except for any information that must be maintained for screening log 
purposes.  
In most cases, the initial contact with the prospective subject will be conducted by either the 
treatment team, investigator or the research staff working in consultation with the treatment team. 
The recruitment process outlined presents no more than minimal risk to the privacy of the patients 
who are screened and minimal protected health information (PHI) will be maintained as part of a 
screening log. For these reasons, we seek a (partial) limited waiver of authorization for the purposes 
of (1) reviewing medical records to identify potential research subjects and obtain information 
relevant to the enrollment process; (2) conversing with patients regarding possible enrollment; (3) 
handling of PHI contained within those records and provided by the potential subjects; and (4) 
maintaining information in a screening log of patients approached (if applicable). 
 
Estimated breakdown of target population: 
 
% Native American/Alaskan 0% 
% Asian/Pacific Islander 
16% 
% Black Non Hispanic 
12% 
% Hispanic 
 
 
8% 
% White Non-Hispanic 
64% 
% Other 
 
 
0% 
 
8.0 
PRETREATMENT EVALUATION 
 
There will be a chart review to ensure the patient meets eligibility criteria. Primary pre-
treatment evaluation will be based on the evaluation performed as part of the patient’s 
regular medical care at MSKCC. Additional pre-treatment evaluation will include:  
 
History and physical examination 
 
Laboratory studies (within 2 weeks before study entry): 
 
Chemistry: Comprehensive metabolic panel including glucose, urea nitrogen, creatinine, 
eGFR, calcium, protein, albumin, bilirubin, AST, ALT, LDH, alkaline phosphatase 
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 
Hematology: CBC, differential count, platelet count. 
 
Pregnancy test to be performed on female patients of childbearing potential within 1 week 
before administration of radioactive material. 
 
Clinically available imaging studies will be reviewed, including CT, FDG and or MRI and 
other available studies, such as  bone scans. These studies must be from within 4 weeks 
of 89Zr-DFO-trastuzumab injection. 
9.0 
TREATMENT/INTERVENTION PLAN 
9.1  
Pharmacokinetics  
Patients are not required to fast before 89Zr-DFO-trastuzumab injection or imaging. 
Catheter insertion and Pharmacokinetics  
If feasible, patients in cohort 1 will have 2 intravenous catheters (Hep-Lock) placed by staff in 
the Molecular Imaging and Therapy Service for radiopharmaceutical administration and 
blood sampling, or alternatively a central line may be used for injection or sampling. The 
intravenous placed catheter for injection and/or blood draw during study will be removed at 
the conclusion of the imaging session. If two lines are not feasible, one line will be used for 
both injection and PK sampling with intervening 10 cc saline flush and change of catheter 
hub. Patients in Cohort 2 (no pharmacokinetics), will not require a second catheter. 
To determine pharmacokinetic and for possibly metabolite analysis of the drug, patients 
undergoing pharmacokinetics will have serial blood samples drawn:  
 
Blood sample, 4-6 mL of blood will be drawn in a speckled top serum separator 
tube.  
 
Blood will be centrifuged in Dr. Carrasquillo’s lab, and the serum pipetted and 
counted. Samples may be tested for breakdown products by TCA or HPLC.   
 
Blood draws will be done prior to injection of 89Zr-DFO-trastuzumab     (baseline), 
approximately baseline, 5 ± 2, 15 ± 5, 30 ± 9, 60 ± 19, and 120 to 240 minutes 
after injection of the tracer. One sample at the time of each subsequent day of 
imaging (24 , ~48-96h and ~120-192h post injection, in order to build in flexibility 
after the initial injection  day we will allow ± 8h of stated times). 
 
Pharmacokinetic parameters will be obtained including Concentration at time 0, 
Volume of distribution of central compartment (Vc), clearance,T1/2 and AUC.  
9.2 
Imaging 
PET scanning: In order to provide reproducible clinical data, we will acquire all 89Zr-DFO-
trastuzumab PET scans on the GE PET-CT scanner DSTE at MSKCC or the same type or a 
newer generation scanner. Once a study is begun in one scanner, it will be continued on the 
same scanner unless malfunction/emergency issues prevent this.  Intravenous injection of 
89Zr-DFO-trastuzumab (maximum of 5 mCi ± 10%) will be given over 5-10 minutes. Initially 
we will start with ~ 5 mCi of 89Zr-DFO-trastuzumab; the activity may be adjusted downward 
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Page 21 of 44 
 
based on visual review of image quality. A PET-CT scan extending from mid skull to proximal 
thighs will be performed to determine the biodistribution. For patient undergoing serial 
scanning one scan will be performed utilizing low mA (80 mA) and on subsequent days, we 
will use 10 mA in order to minimize radiation exposure.   
Patients undergoing pharmacokinetics will also have imaging at 4 time points post-injection 
to allow for selection of optimal imaging time and dosimetry determination.   
 Within one to four hours following injection of tracer on Day 0 
 ~24 ± 8hours post-injection (Day 1) 
 ~4896 hours post-injection (once during Days 24) ±8h 
 ~120192hours post injection (once during Days 58)±8h 
Imaging will be in 3D, typically from mid skull to midthigh (approximately 6-7 bed positions) to 
allow for estimates of whole organ uptake and excretion patterns. These whole body studies 
will vary in duration according to the height of the patient but will typically be 21-60 minutes in 
duration.  
 
Active lesions will be identified (Molecular Imaging investigator) based on review of the 
patients conventional images and treatment history (i.e. external radiation). A PET positive 
lesion will be considered present if there is greater localization than that expected based on 
blood pool distribution of the tracer. Given that at present we do not know the heterogeneity 
of the antigen between lesions or between primary and metastatic disease a patient will be 
considered positive if any of the active lesions are identified with the 89Zr-DFO-trastuzumab. 
We will, nonetheless tabulate the number of lesions and their status based on 89Zr-DFO-
trastuzumab. When pathologic material that has been evaluated for the presence of HER2 is 
available for any specific lesion, we will correlate the presence of HER2 with imaging results. 
Images will be analyzed with ROI and SUVmean and max measurements will be obtained. 
The serial quantitative data obtained over the various organs of interest (heart, liver, spleen, 
kidney, lung and any other organ that exhibits uptake will be collected.  These data can then 
be utilized to determine organ time activity curves and the dosimetry can be calculated. 
Uptake and clearance values will be summarized using descriptive statistics (mean, median, 
standard deviation). Once the biodistribution and pharmacokinetics have been characterized, 
subsequent patients will not require serial imaging and pharmacokinetics, but rather will have 
a single scan at an optimal time point determined  from the initial cohort. We will determine 
the time at which the greatest number of lesions are seen. This is likely to be between 3-8 
days, but choice will be based on the first Cohort 1 patients’ data, using the most frequent 
day at which the most lesions are seen and/or at times at which best contrast is observed, 
determined visually.  Thus, for the remainder of the patients, PET scan will be performed 
once.   
Images will be stored as Digital Imaging and Communications in Medicine (DICOM) on the 
PACS and HERMES. No decision on the patients’ health care management will be made 
based on imaging with 89Zr-DFO-trastuzumab scan. 
9.3 
Whole body probe measurements (Cohort 1) 
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Patients undergoing pharmacokinetics and serial imaging will undergo whole body activity 
measurement using a NaI probe placed at ~3.3 yards from the patient using our standard 
procedure. These measurements will be performed the day of injection of 89Zr DFO-
trastuzumab before voiding (if patient has to void before the initial measurement, urine will be 
collected and counted together with the patient) and after first void, and at each time the 
patient returns for imaging (typically probe count are acquired in less than 6 minutes). 
9.4 
Assessment for Toxicity 
Safety Outcome Measures (CTCAE v4) 
Infusion Reaction 
Infusion reactions with 89Zr-DFO-trastuzumab at these low milligram administration are 
expected to be infrequent. In the event of fever, rigors, shortness of breath, or other evidence 
of infusion reaction, patients may receive diphenhydramine 25-50 mg IV and Tylenol 650 mg 
PO as felt to be clinically appropriate by the treating physician.   
Patients will be monitored during and after 89Zr-DFO-trastuzumab infusion for 60 minutes 
after the infusion. Patients who experience infusion-related symptoms should be 
managed as directed in Table 1. 
The safety and tolerability of 89Zr-DFO-trastuzumab w i l l  be assessed using the 
following primary safety outcome measure: 
 
Incidence, nature, and severity of adverse events up to day 14 by phone 
following antibody administration. 
 
Change in vital signs during administration 
Table 1 
Management of Infusion-Related Symptoms 
 
Infusion-Related 
Symptoms 
Guidance 
Grade 1 
 
Slow or hold infusion 
 
Give supportive treatment 
 
Upon symptom resolution, may resume infusion rate escalation 
at the investigator’s discretion 
Grade 2 
 
Slow or hold infusion 
 
Give supportive treatment 
 
Upon symptom resolution, may resume infusion-rate escalation 
at the investigator’s discretion 
Grade 3 or Grade 4 
 
Discontinue infusion 
 
Give supportive treatment 
Patient may be imaged if sufficient tracer has been administered and 
the patient is stable, at the discretion of the administering investigator. 
 
Given that this is a humanized antibody and that it is administered repetitively to patients, no 
determination of human anti human antibody will be performed as part of this study. 
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10.0 EVALUATION DURING TREATMENT/INTERVENTION 
Laboratory Safety Assessments 
Blood testing:  
Hematology and blood chemistry assessments (CBC, serum BUN, creatinine, AST, ALT, total 
bilirubin, alkaline phosphatase, albumin and blood glucose levels) will be done at the time points 
described in Flowchart 1. Additional blood tests may also be performed at the discretion of the 
investigator for the purposes of planning treatment administration, dose modification, or investigation 
and follow-up of adverse events.  
Physical examination:  
A physical examination including, but not limited to, general appearance, skin, neck, eyes, ears,  
throat, lungs, heart, abdomen, lymph nodes, extremities, and nervous system will be performed. The 
physical examination will include examination of known and suspected sites of disease. Physical 
examination results, height and weight will be recorded at baseline.   
Performance Status 
Performance status will be assessed using the Karnofsky Performance Status scale (Appendix 1). 
Vital Signs 
Blood pressure and heart rate will be obtained at the time points outlined in the flowchart. 
 
Flowchart Cohort 1  
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Screeninga 
 
Day 
0 
 
Day 
1 
 
Days 
2-4 
 
Days 
5-8 
 
~14 days 
post dose 
Within 4 
weeks 
Within 
14 days  
Informed consent 
X 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
Concomitant medications 
X 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
Performance status 
X 
 
 
 
 
 
 
Vital signsb 
X 
 
X 
 
 
 
 
Laboratory studiesc 
 
X 
 
 
 
X 
 
Radiographic studiesd, e 
X 
 
 
 
 
 
 
IHC and or FISH for HER2f 
Prior to 
enrollment 
 
 
 
 
 
 
89Zr DFO-trastuzumab 
tracer administration 
 
 
X 
 
 
 
 
Adverse events on day of 
imaging 
 
 
X 
X 
X 
X 
 
Phone assessmentg 
 
 
 
 
 
 
X 
Serial whole-body scansh 
 
 
X 
Xi 
Xi 
Xi 
 
Serial whole-body probej 
 
 
X 
Xi 
Xi 
Xi 
 
Serial blood samplesj  
 
 
X 
Xi 
Xi 
Xi 
 
 
a 
Screening evaluation should be performed following informed consent and within 4 weeks before 
study entry, except when noted otherwise. Evaluations performed as standard of care before informed 
consent but within the 4-week window need not be repeated. 
b 
Vital signs will be monitored prior to infusion and approximately every 30 minutes (± 5 minutes) for at 
least 2 h or later if the patient is still in the department for imaging. If no changes are observed in the 
first 10 patients subsequent patiens will be monitored for 1 h post injection. 
c  
All laboratory studies are to be performed up to 2 weeks before study entry . 
d 
Radiographic evaluations include  CT of chest, abdomen and pelvis (MRI is acceptable ), and modified 
MRI of the pelvis, if clinically indicated. All radiographic studies are to be performed within 4 weeks 
before. 
e 
Radiographic post treatment work up will be performed as per patient’s therapy protocol or as per 
standard of care. 
f  
HER2 status performed at MSKCC or elsewhere will be  acceptable. 
g 
A phone call will be used to assess for changes in concomitant medications and any adverse events 
after all scans have been completed. 
h 
Following injection with the 89Zr DFO-trastuzumab tracer, the patients enrolled will have serial whole-
body PET-CT scans (WBS) performed to determine the biodistribution of the tracer. PET scans  will be 
acquired: 14 hours following injection of the tracer, ~24 hours post-injection, ~4896 hours post 
injection, and ~120192 hours post injection the 24 h and other later scans will be performed within a 
±8h of stated times. 
i 
Only serial measurement in first 10 patients. All subsequent patients will not have serial blood draws, 
probe measurements or imaging, but rather one single imaging at a time point that is optimum based 
on the initial cohort of patients 
j      For the first 10 patients enrolled, serial blood samples will be obtained for biodistribution, metabolite 
analysis of the 89Zr DFO-trastuzumab compound will be performed on selected samples. Samples will 
be obtained just prior to injection of the 89Zr DFO-trastuzumab tracer this sample will be banked at -
80degree C for future testing for immune response (HAHA) if altered biodistribution is observed., and 
at 5 ± 2 minutes, 15 ± 5, 30 ± 9, 60 ± 19 minutes, and 120  240 minutes after the injection of the 
Memorial Sloan Kettering Cancer Center
IRB Number: 13-165 A(12)
Approval date: 30-Nov-2020

 
  
 
Page 25 of 44 
 
tracer 1, and at the time of each subsequent day of imaging. Additionally, whole body counts (WBC) 
using a NaI probe will be performed during the imaging in the first 10 patients and the exact time 
recorded: 
o 
Within 0.1 to 3 hours following injection of tracer on Day 1 (prior to voiding) and post 
voiding 
o 
~24 hours post-injection (Day 1)±8h 
o 
~4896 hours post-injection (once during Days 24)±8h 
o 
~120192 hours post injection (once during Days 58) ±8h 
Documentation of actual times of blood draw and probe measurement is required. 
 
 
 
 
 
 
 
 
 
 
 
 
 Flowchart Cohort 2  
 
Screeninga 
 
Day 0 
 
Day 
TBD 
 
~14 days 
post dose 
Within 4 
weeks 
Within 7 
days  
Informed consent 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
Medical history 
X 
 
 
 
 
Concomitant medications 
X 
 
 
 
 
Physical exam 
X 
 
 
 
 
Performance status 
X 
 
 
 
 
Vital signsb 
X 
 
X 
 
 
Laboratory studiesc 
 
X 
X 
Xc 
 
Radiographic studiesd 
X 
 
 
X 
 
IHC and or FISH for 
HER2e 
Prior to 
enrollment 
 
 
 
 
89Zr DFO-trastuzumab 
tracer administration 
 
 
X 
 
 
Adverse events 
 
 
X 
X 
 
Phone assessmentf 
 
 
 
 
X 
Single whole-body scans  
 
 
 
Xg 
 
a 
Screening evaluation should be performed following informed consent and within 4 weeks before 
study entry, except when noted otherwise. Evaluations performed as standard of care before 
informed consent but within the 4-week window need not be repeated. 
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IRB Number: 13-165 A(12)
Approval date: 30-Nov-2020

 
  
 
Page 26 of 44 
 
b 
 Vital signs will be monitored prior to infusionand approximately every 30 minutes (± 5 minutes) for 
at least 2 h or later if the patient is still in the department for imaging. 
c 
Within 1 week of second injection and day of imaging. On Day 0, on injection 1 serum sample 3cc, 
will be collected and frozen at -80degree for testing of immune (HAHA) response if altered 
biodistribution is observed. 
d 
Radiographic studies as per clinical routine for assessment of response. 
e 
HER2 status performed at MSKCC or elsewhere will be  acceptable. 
f 
A phone call will be used to assess for changes in concomitant medications and any adverse 
events after all scans have been completed.  
g  
Single imaging time point based on cohort 1 (likely to be from day 3 to 8) 
 
11.0 TOXICITIES/SIDE EFFECTS 
Risks 
89Zr-DFO-trastuzumab     
Overall our experience with other radiolabeled antibodies and radiolabeled trastuzumab are that 
allergic reactions are uncommon.  Therefore no pretreatment will be provided before antibody 
injection. Potential risks associated with 89Zr-DFO-trastuzumab  are similar to those of other 
humanized antibody and include allergic reactions, characterized by fever, chills, and sometimes 
rashes or hives.  Less likely shortness of breath or gastrointestinal upset can occur. Rare allergic 
reactions can present as shock or death or swelling of the throat. Heart failure, although observed 
with therapeutic doses of trastuzumab are not expected at these lower ~ 50mg x 2 doses. Allergic  
reactions are usually addressed by stopping the administration of the drug, administering 
diphenhydramine , acetaminophen and/or steroids, and restarting the drug at a slower rate if the 
reaction is not severe.  We will also follow MSKCC  guidelines for “adult hypersensitivity orders for 
chemotherapy/biologic therapy”, which intstitutes therapy according to the severity of the reaction.  
There is a very small risk of infection. This could cause itching or redness at the area on the 
patient’s arm where the IV was placed.  
89Zr DFO-trastuzumab PET/CT Scans 
As part of this scan there is radiation delivered from the 89Zr and from the low dose CT scan that are 
performed as part of the CT for attenuation correction and co-registration. Although any exposure to 
ionizing radiation has the potential to cause some harm to tissue, the radiation exposures in this 
study are comparable to the low-level exposures associated with common diagnostic procedures 
such as CT scanning. There remains a low theoretical risk of developing a cancer at some point 
later in life because of the radiation exposure received in this study. This risk is particularly low for 
adults given the fact that the radiation from the scans will be over several weeks. Participants should 
avoid pregancy while on this study. Acceptable birth control methods include abstinence, double 
barrier method, surgically sterilized patient or partner. This risk is much smaller that the clinical risks 
posed by the patient’s current cancer.  
Radiation Dosimetry 
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Normal-organ radiation absorbed doses and the effective dose for 89Zr-DFO-trastuzumab in human 
were estimated based on measured time-activity data in mice. The time-activity data (percent of the 
injected dose per gram (%ID/gm) versus time (t) post-administration) for each organ were fit to an 
exponential functions and the resulting function were analytically integrated (incorporating the 
radioactive decay of 89Zr) to yield the residence time (cumulated activity) of 89Zr in each organ. The 
mouse organ 89Zr residence times were converted to 89Zr residence times in human organs (for the 
70-kg Standard Man anatomic model) by adjusting for the difference in fractional organ masses 
between mice and humans. The resulting human residence times were then entered into the 
OLINDA/EXM radionuclide dosimetry program, which implements the MIRD (Medical Internal 
Radionuclide Dosimetry) algorithm, to yield the normal-organ radiation absorbed doses (in cGy) and 
effective dose (in rem) for 89Zr-DFO-trastuzumab in man.  Assuming a 5-mCi administered activity of 
89Zr-DFO-trastuzumab and a low-dose (80 mA) and three very-low-dose (10-mA) CT scans are to be 
performed, with approximate CT effective doses of 0.90 rem and 0.11 rem the radiation dosimetry is 
tabulated below to include the second injection of  89Zr-DFO-trastuzumab, that some patients may 
receive (Table 2). 
 
 
 
Table 2 
# of Injections/CT scans 
Activity of 89Zr-DFO-trastuzumab 
5 
mCi 
2 
low dose CT scan (80mA) 
0.9 
cGy 
2 
ultra-low dose CT scan (10mA) 
0.11 
cGy 
3 
Absorbed Dose 
89Zr-DFO-trastuzumab 1 
Total dose from CT and  up to 2 89Zr-
DFO-trastuzumab + CT 
Target Organ 
cGy/mCi 
cGy per inj 
cGy 
Adrenals 
1.47 
7.4 
16.8 
Bone Surfaces 
3.36 
16.8 
35.7 
Brain 
0.64 
3.2 
8.5 
Heart Wall 
1.32 
6.6 
15.3 
Kidneys 
2.45 
12.3 
26.6 
Large Intestine - Lower Wall 
1.08 
5.4 
12.9 
Large Intestine - Upper Wall 
1.06 
5.3 
12.7 
Liver 
2.96 
14.8 
31.7 
Lungs 
2.07 
10.4 
22.8 
Ovaries 
1.00 
5.0 
12.1 
Pancreas 
1.33 
6.7 
15.4 
Red Marrow 
2.76 
13.8 
29.7 
Small Intestine 
1.08 
5.4 
12.9 
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IRB Number: 13-165 A(12)
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Page 28 of 44 
 
 
In accordance with local and Federal regulations (USNRC), patients administered 89Zr can be 
released from hospital control when it can be demonstrated that a member of the public is unlikely to 
receive greater than 1 mSv. Conservative regulatory guidance suggests that in the case of 89Zr, a 
patient can be released from hospital control if either of the following conditions apply: they receive < 
5 mCi or the dose rate at 1 meter from the patient is < 4 mrem/h.  In a subset of 10 patients from a 
previous protocol who received a mean activity of 5 mCi 89Zr-J591, the measured dose rate at 1 
meter averaged 1.9 mrem/h and the maximum dose rate was 2.3 mrem/h. As these values are 
demonstrated to be well below 4 mrem/h, patients administered 5 mCi 89Zr for this current diagnostic 
protocol can be released from hospital control without the need for specific radiation safety 
measurements. 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT 
We will determine the toxicity, optimum imaging time and the feasibility of using 89Zr-DFO-
trastuzumab as an imaging agent in esophagogastric tumors that express HER2.  In a pilot manner 
we will quantitatively evaluate changes in tumor concentration compared to baseline scan, once 
patients undergo HER2 directed therapy and a second 89Zr-DFO-trastuzumab     imaging study.    
Decay corrected images will be assessed, SUVmax and mean values for regional dose distribution 
will be calculated, and converted using excel into values that can be entered into the OLINDA 
software package that will ultimately calculate the absorbed doses.   
Positive lesions on 89Zr-DFO-trastuzumab will be defined visually as a focus of  accumulation of  
radioactivity that is deemed to not be physiologic and is higher than adjacent or contralateral 
background.  Antibody scan will be read blinded from clinical history and conventional imaging 
modalities. Two different experienced, blinded readers will visually analyze the 89Zr-DFO-
trastuzumab scans, and SUVmax/mean will be determined in lesions identified and in normal organs 
and blood pool. To study the accumulation and biodistribution of 89Zr-DFO-trastuzumab     in patients 
with esophagogastric cancer, the accumulation of 89Zr-DFO-trastuzumab will be assessed for each 
site and compared with the clinically established lesion in the  baseline radionuclide bone scan, FDG 
PET/CT,  CT, and/or MRI imaging. The definition of a positive lesion will be a lesion identified by an 
experienced reader on conventional imaging CT/MRI, and/or FDG scan consistent with metastatic 
Spleen 
2.30 
11.5 
25.1 
Stomach Wall 
1.33 
6.7 
15.4 
Testes 
0.62 
3.1 
8.3 
Thyroid 
0.75 
3.8 
9.7 
Urinary Bladder Wall 2 
1.83 
9.2 
20.4 
Uterus 
0.98 
4.9 
11.9 
Total Body 
1.06 
5.3 
12.7 
Effective Dose (rem) 
1.48 
7.4 
  
16.9 
1 Based on biodistribution of 89Zr-89-DFO-trastuzumab in nude mice 
(Holland et al,  PLoS ONE 5(1): e8859. doi:10.1371/journal.pone.0008859) 
OLINDA/EXM-based absorbed dose estimates by Pat Zanzonico 
2 (assumed 3-hr voiding interval) 
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Page 29 of 44 
 
disease, as is currently done clinically.  Lesions on 89Zr-DFO-trastuzumab or conventional imaging 
will be read in a scale of 1 to 5, 1= negative, 2 = probably negative, 3= not sure, 4= probably positive 
and 5= definitively positive. Once this is done, a consensus master list of lesions will be created that 
compares all imaging conventional imaging modalities(CT/MRI, FDG PET, bone scan), only those 
lesions that are conspicuously positive (i.e., “4 or 5”) by imaging will be considered as a positive site 
of disease. Discrepant findings between findings on conventional imaging and 89Zr-DFO-
trastuzumab modalities will be considered false positive or false negative.  Although it would be ideal 
to biopsy any site that is considered abnormal this is not logistically feasible or ethically acceptable. 
Successful imaging will be considered a positive imaging in  > 70% of patients .  One or 2 non-
blinded readers (access to clinical, laboratory and imaging data) will identify “positive lesions” .  
As a first level, we will compare site by site. Since the individual modalities are based on different 
mechanisms of uptake, they may not have exact correspondence in space, since bone scan is a 2D 
modality and  89Zr looks at tumor antigen expression and is a 3D modality. For this purpose, we have 
made a list of standardized anatomic sites, to make sure that a positive lesion would have a positive 
89Zr-DFO-trastuzumab uptake. As a second level, we will compare lesion by lesion.   
12.1 
CT and MRI 
Available CT and/or MRI imaging done clinically will be used as a correlative diagnostic imaging tool 
to compare to results of 89Zr-DFO-trastuzumab PET scanning. Furthermore soft tissue lesions 
greater than 2 cm on CT or MRI will also be compared to 89Zr-DFO-trastuzumab in order to 
overcome the issues of partial volume. 
 
13.0 
CRITERIA FOR REMOVAL FROM STUDY 
Participation in the study is strictly voluntary. Patients have the right to withdraw from the study at 
any time. If a patient chooses to withdraw, he or she must inform the investigator immediately. In 
addition, the investigator has the right to terminate participation of any patient at any time if it is 
deemed in the patient’s best interest. The reason and circumstances for premature discontinuation 
will be documented in the patient’s medical records. Possible examples for reasons of premature 
study withdrawal include withdrawal of consent, SAE or intolerable AE, or any other medical illness 
at investigator’s discretion. 
14.0 
BIOSTATISTICS 
14.1 
Primary Objective 
This is a pilot trial.  The primary objective of this protocol is to determine the feasibility, 
safety and tolerability of administration of 89Zr-DFO-trastuzumab     antibody. 
Definition of Feasibility: Antibody imaging is considered feasible if 70% of the patients are 
antibody-imaging positive as defined below. 
Defintion of Antibody-Positive: A patient with HER2 positive tumor will be considered 
antibody-imaging-positive if 50% or more of the active lesions (FDG positive, bone scan 
positive or CT positive >2cm)  are detectable in any of the scanning time points (4 scans in 
the first 10 patients and 1 scan in all others). Active lesion means any lesion that was 
identified by conventional imaging methods and clinical data at baseline felt to represent 
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tumor. We have selected a threshold of  50% for this first imaging study for 3 reasons: 1) we 
do not know what the heterogeneity of antigen expression is within a number of lesions in the 
same patient; 2) we will consider positive any lesion based on conventional clinical imaging 
criteria, in which case some lesions considered positive may be false positive and more 
importantly 3) our main long term emphasis is to evaluate whether this imaging will identify 
HER2 positive patients and whether identification of these patients for treatment with HER2 
directed therapies will be of benefit.   Thus, we do not want to discard this agent if we can 
use it as a theranostic (defined as an agent that is integrated into the drug development 
process to guide patient selection and drug development), for the development of therapeutic 
regimens aimed at HER2. Nonetheless, we intend to evaluate treatment response of all 
available lesions in this way we will maximize our ability to determine the relationship 
between uptake of antibody and response. 
The optimal time for imaging will be estimated based on results from the first 10 patients 
studied.   In each of the first 10 patients the proportion of lesions idenfied on each imaging 
day will be determined.  The  imaging day in which the greatest proportion of lesions are 
identified for each patient will be identified.  The optimal day for imaging will be the one most 
frequently associated with the visualization of the largest proportion of lesions in the first 10 
patients.  Since it is possible that the same proportion of lesions may be identified over 
several days and that contrast may vary between the different imaging days  a consensus 
visual assessment of a group of experienced Molecular Imaging and Therapy investigator 
who will grade the studies separately (JAC, SML and NPT, 2 of the readers will be blinded to 
clinical information),  will  be used to make the final decision. 
Evaluation of Feasibility in the First Cohort: Antibody imaging will be considered feasible if 7 
or more of the 10 patients in the first cohort are antibody-imaging-positive.We will also 
require that none of these patients experience severe toxicity attributable to the initial 
antibody. The following table provides the one-sided 90% confidence limit for the true 
feasibility rate based on the number of feasible patients: 
Number of Feasible Patients  
7 
8 
9 
10 
One-sided 90% CL 
 
 
45% 
55% 
66% 
79% 
If less than 70% of patients are considered positive for imaging in either the first cohort  or 
combination of first and second cohort the study will be closed.   
Tolerability: If the study proceeds to cohort B, one-sided exact confidence limits will be used 
to estimate the toxicity and feasibility rates at the end of the study using all the 55 patients. 
The following tables give some of the likely outcomes to be observed: 
Number of Patients with Toxicity 
 
0 
1 
2 
One-sided 90% CL 
 
 
 
9% 
15% 
20% 
Evaluation of Feasibility in the Second Cohort: 
Number of Feasible Patients  
20 
21 
22 
23 
24 
25 
One-sided 90% CL 
 
 
66% 
71% 
75% 
80% 
85% 
91% 
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Dosimetry and PK: Another objective is to determine the organ/tissue uptake and dosimetry 
following IV injection of 89Zr-DFO-trastuzumab  in patients with HER2 positive tumors. The 
group for this analysis will comprise  10 HER2+ patients in the cohort 1 89Zr-DFO-
trastuzumab study the 10 patients that will be recruited in the treatment assessment arm. 
Standardized uptake value (SUV based on weight and lean body mass) in various organs will 
be measured and summarized over patients to describe the organ and tissue uptake of the 
tracer. The SUVmean, max and peak will be summarized with descriptive statistics.  This 
data will be converted to residence time and will be used in OLINDA dosimetry program to 
obtrain dosimetry measurements. The dosimetry estimates will be summarized with 
descriptive statistics. 
 
Pharmacokinetic analysis will be performed using a non-compartmental analysis (SAAM or 
GraphPad V5); standard parameters such as AUC, clearance, volume of distribution of 
central compartment, and Co will be reported. Descriptive statistics will be tabulated.  These 
patients will undergo a single whole-body scan at the optimal time point. The ability of 89Zr-
DFO-trastuzumab to detect tumors will be estimated from this cohort using the proportion of 
antibody-imaging-positive patients (within +/-23% if the true detection rate is 70%).   
Toxicity: This study does not intend to find the maximal tolerated dose of 89Zr-DFO-
trastuzumab. This is a diagnostic agent that is expected to have low incidence of adverse 
events.  Patients will be monitored closely looking for evidence of adverse events.  Because 
most patients are expected to start new therapies within 2 weeks of receiving  89Zr-DFO-
trastuzumab only short term toxicity will be evaluated. The safety and tolerability of 89Zr-DFO-
trastuzumab will be assessed using the following primary safety outcome measures: 
Incidence and nature and severity of adverse events; and change in vital signs and clinical 
laboratory results. Incidence and severity of adverse events will be summarized with 
descriptive statistics. 
If severe adverse effect (grade 3 or 4 CTCAE) attributable to 89Zr-DFO-trastuzumab is 
observed in any cohort we will review with  MSKCC-DSMC.  A secondary objective is to 
correlate 89Zr-DFO-trastuzumab  imaging to response to treatment in those patients recruited 
for repeat imaging following therapy.  Outcome measures to be correlated include those that 
are outlined in any parent protocol under which the patient is receiving treatment (typically 
RECIST,survival or progression free survival).  
Secondary Analysis: Preliminary quantitative data will be obtained using SUV measurements 
on baseline study compared to that of patients having repeat 89Zr-DFO-trastuzumab 
study(n=10).  Paired T-test will be performed to estimate the differences. With 10 patients 
having repeat imaging. 
Imaging result based on mean SUV measurements will be tabulated  and compared to 
clinical response (stable, regression or progression).  Furthemore we will be identify lesion 
outcome (stable, regression or progression) based on the individual lesion SUV. The data 
will be expressed in terms of stable, regression and progression versus mean SUV 
measurement and summarized in terms of descriptive statistics.  
 
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IRB Number: 13-165 A(12)
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Page 32 of 44 
 
 
 
15.0 
 RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
15.1 
Research Participant Registration 
Confirm eligibility as defined in the section entitled Criteria for Patient/Subject Eligibility. 
Obtain informed consent, by following procedures defined in section entitled Informed 
Consent Procedures. 
During the registration process registering individuals will be required to complete a protocol 
specific Eligibility Checklist. 
All participants must be registered through the Protocol Participant Registration (PPR) Office 
at Memorial Sloan-Kettering Cancer Center. PPR is available Monday through Friday from 
8:30am – 5:30pm at 646-735-8000. Registrations must be submitted via the PPR Electronic 
Registration System (http://ppr/).  The completed signature page of the written consent/RA or 
verbal script/RA, a completed Eligibility Checklist and other relevant documents must be 
uploaded via the PPR Electronic Registration System. 
 
 15.2 Randomization 
This research study does not require randomization procedures. 
16.0 
DATA MANAGEMENT ISSUES 
A Research Study Assistant (RSA) will be assigned to the study. The responsibilities of the RSA 
include project compliance, data collection, abstraction and entry, data reporting, regulatory 
monitoring, problem resolution and prioritization, and coordinate the activities of the protocol study 
team.   
The data collected for this study will be entered into a secure database. Source documentation will 
be available to support the computerized patient record. 
Study personnel will record clinical data in each patient’s source documents (i.e., the patient’s 
medical record).  
The investigator will maintain adequate and accurate records to enable the conduct of the study to 
be fully documented and the study data to be subsequently verified. After study closure, the 
investigator will maintain all source documents, study-related documents, and the data stored in the 
database used for data collection. Records will be retained and securely stored for a minimum of 2 
years after the completion of all study activities. 
Data will be entered throughout the duration of the trial as patients are enrolled. Accrual is expected 
to last 18 month. 
 
 
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Page 33 of 44 
 
16.1 
Quality Assurance 
Regularly scheduled registration reports will be generated to monitor patient accruals and the 
completeness of registration data. Routine data quality reports will be generated to assess 
missing data and inconsistencies. Accrual rates and the extent and accuracy of evaluations 
and follow-up will be monitored periodically throughout the study period, and potential 
problems will be brought to the attention of the principal investigator for discussion and 
action. 
Random-sample data quality and protocol compliance audits will be conducted by the study 
team at least once a year, more frequently if indicated. 
16.2 
Data and Safety Monitoring 
The data and safety monitoring (DSM) plans at MSKCC were approved by the National 
Cancer Institute in September 2001. The plans address the policies set forth by the NCI in 
the document entitled Policy of the National Cancer Institute for Data and Safety Monitoring 
of Clinical Trials, which can be found at http://cancertrials.nci.nih.gov/clinicaltrials. The DSM 
plans at MSKCC were established and are monitored by the Office of Clinical Research. The 
MSKCC DSM plans can be found on the MSKCC Intranet at: 
http://mskweb5.mskcc.org/intranet/html/70775.cfm. 
There are several different mechanisms by which clinical trials are monitored for data, safety, 
and quality. There are institutional processes in place for quality assurance (e.g., protocol 
monitoring, compliance and data verification audits, therapeutic response, and staff 
education on clinical research quality assurance) and departmental procedures for quality 
control, and there are two institutional committees that are responsible for monitoring the 
activities of our clinical trials programs. The committees: Data and Safety Monitoring 
Committee (DSMC) for Phase I and II clinical trials, and the Data and Safety Monitoring 
Board (DSMB) for Phase III clinical trials, report to the MSKCC Research Council and 
Institutional Review Board.  
During the protocol development and review process, each protocol will be assessed for its 
level of risk and degree of monitoring required. Every type of protocol (e.g., NIH sponsored, 
in-house sponsored, industrial sponsored, NCI cooperative group, etc.) will be addressed, 
and the monitoring procedures will be established at the time of protocol activation. 
For this protocol, we will use the following patient safety monitoring plan and monitoring for 
adverse events, in terms of the test performed and their timing relative to injection (see 
Flowchart 1 and Flowchart 2).  Patient will be observed closely during infusion and serial vital 
signs will be monitored every half hour for at least 2 h or later if the patient remains in the 
department. Patients will be queried for adverse events up to ~14 days after infusion.  
Safety reviews will be performed by the MSKCC-DSMC with yearly review by the IRB. 
 
 
16.3 DOD Requirements 
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IRB Number: 13-165 A(12)
Approval date: 30-Nov-2020

 
  
 
Page 34 of 44 
 
Per DoD Directive 3216.02, all greater than minimal risk studies require a Medical 
Monitor.  
Responsibilities of the Medical Monitor 
The medical monitor is required to review all unanticipated problems involving risk to 
subjects or others, serious adverse events, and all subject deaths associated with the 
protocol and provide an unbiased written report of the event. 
Medical Monitor: Lisa Bodei, MD  
Lisa Bodei, MD will serve as an independent clinical monitor of the research trial and will 
oversee the conduct and expectations of fulfilling its research goals and obligations. She 
will be meeting with the Principal Investigator to review any relevant toxicities incurred by 
patients and to determine whether the study accrual is being conducted in a timely and 
efficient manner. Lisa Bodei, MD is a qualified physician, other than the Principal 
Investigator, not associated with this particular study who possesses sufficient 
educational and professional experience to serve as the subject/patient advocate. As the 
medical monitor, Dr. Lisa Bodei may: 
 
Stop a research study in progress 
 
Remove an individual from the study 
 
Take any steps to protect the safety and well-being of participants until the IRB 
can assess  
The DOD funding supporting this study expired in 09/2019. 
 
17.0 
PROTECTION OF HUMAN SUBJECTS 
This study will be conducted in compliance with the protocol, GCP guidelines established by the 
International Conference on Harmonization, and the ethical standards set forth in the Declaration of 
Helsinki 2004 (available at: www.laakariliitto.fi/e/ethics/helsinki.html). 
A limited waiver of authorization will be utilized to effectively screen and track patients in screening, 
however the recruitment process outlined presents no more than minimal risk to the privacy of the 
patients who are screened and minimal protected health information (PHI) will be maintained as part 
of a screening log. 
This protocol does not have therapeutic intent and does not offer patients therapeutic benefit. This 
will be clearly conveyed to patients when communicating the potential toxicities/side effects of 
participating in this trial. Participation in the trial is voluntary and there will be no financial benefit (or 
burden) for the patients. Participants will not be charged for 89Zr-DFO-trastuzumab PET scans, 
whole body probe counts, radiotracer drugs, and extra blood draws (to measure radiotracer activity). 
When all other possibilities are exhausted, if an eligible patient lives outside of New York City, then 
the patient will be eligible for reimbursement for the costs of parking/ public transportation (up to $50 
per day with receipt) and a two-night stay at an MSKCC approved hotel (up to $1000 total), when 
those costs are incurred during the days that the patient visits the Main Campus Radiology 
Department for study injection and scans. 
17.1 
Privacy 
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MSKCC’s Privacy Office may allow the use and disclosure of protected health information 
pursuant to a completed and signed Research Authorization form. The use and disclosure of 
protected health information will be limited to the individuals described in the Research 
Authorization form. A Research Authorization form must be completed by the Principal 
Investigator and approved by the IRB and Privacy Board (IRB/PB).  
 
17.2 
Serious Adverse Event (SAE) Reporting 
An adverse event is considered serious if it results in ANY of the following outcomes:  
 
Death  
 
A life-threatening adverse event  
 
An adverse event that results in inpatient hospitalization or prolongation of existing 
hospitalization 
 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
 
A congenital anomaly/birth defect 
 
Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition 
Note: Hospital admission for a planned procedure/disease treatment is not considered an 
SAE.  
 
SAE reporting is required as soon as the participant signs consent.  SAE reporting is 
required for 30-days after the participant’s last investigational treatment or intervention. Any 
events that occur after the 30-day period and that are at least possibly related to protocol 
treatment must be reported. 
 
If an SAE requires submission to the IRB office per IRB SOP RR-408 ‘Reporting of Serious 
Adverse Events’, the SAE report must be sent to the IRB within 5 calendar days of the event. 
The IRB requires a Clinical Research Database (CRDB) SAE report be submitted 
electronically to the SAE Office as follows:   
For IND/IDE trials: Reports that include a Grade 5 SAE should be sent to 
saegrade5@mskcc.org.  All other reports should be sent to saemskind@mskcc.org. 
 
For all other trials: Reports that include a Grade 5 SAE should be sent to 
saegrade5@mskcc.org.  All other reports should be sent to sae@mskcc.org. 
The report should contain the following information: 
Fields populated from CRDB: 
 
Subject’s initials 
 
Medical record number 
 
Disease/histology (if applicable) 
 
Protocol number and title 
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Data needing to be entered: 
 
The date the adverse event occurred 
 
The adverse event 
 
The grade of the event  
 
Relationship of the adverse event to the treatment (drug, device, or intervention) 
 
If the AE was expected 
 
The severity of the AE 
 
The intervention 
 
Detailed text that includes the following 
o A explanation of how the AE was handled 
o A description of the subject’s condition 
o Indication if the subject remains on the study 
 
If an amendment will need to be made to the protocol and/or consent form 
 
If the SAE is an Unanticipated Problem  
The PI’s signature and the date it was signed are required on the completed report. 
For IND/IDE protocols: 
The CRDB SAE report should be completed as per above instructions.  If appropriate, the 
report will be forwarded to the FDA by the SAE staff through the IND Office. 
 
The radiation doses (on the order of 10 rem) lie well within the “low-dose” range—well 
below the threshold doses (typically on the order of 100 rem or greater) for any known 
deterministic effects. A detailed description of the expected dosimetry from the 89Zr-DFO-
trastuzumab is included (Table 2). The dose of 89Zr-DFO-trastuzumab per administration 
(~5mCi) gives the lowest amount that is expected to  be consistent with the research 
goal, namely, biodistribution, metabolism, and pharmacokinetics of the compound. 
 
 
 
17.2.1  
This protocol will have an IND. SAE will also be reported to the FDA through the IND Office 
and the report will include the FDA assigned BB-IDE, BB-IND or IND number and name. 
Patients will be monitored for adverse events following agent administration. Beginning 
immediately after tracer-injection, patients will be observed for 1 hour in the Radiology 
Department, to monitor for acute adverse reactions. 
Toxicities will be assessed according to the National Cancer Institute CTC Scale (Version 
4.0). 
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An adverse event is defined by the GCP (Good Clinical Practice guidelines) as an 
undesirable experience occurring to a subject during a clinical trial, whether or not 
considered related to the investigational product(s). It is the responsibility of the Principal 
Investigator and his/her research team to identify, review and record all necessary adverse 
events. 
17.3   SAE Grading 
17.3.2 
Grading Severity 
All adverse events will be graded for intensity on a scale of 0 to 5. Severity grades will be 
recorded and based on the CTCAE v4.0. 
17.3.3 
Attributing Causality 
The investigator will evaluate the potential relationship between all clinical AEs, abnormal 
laboratory values, and the 89Zr-DFO-trastuzumab    , and categorize the relationship 
according to the descriptions in Table 3. Abnormal laboratory values of clinical 
significance that were present at baseline and did not change in either severity or 
frequency during the experimental therapy or intervention and/or that can obviously be 
attributed to the underlying disease will be evaluated by the investigator and recorded in 
the “unrelated” category. 
 
 
 
 
 
 
 
Table 3. 
Relationship of Adverse Event to 89Zr-DFO-trastuzumab       
Relationship 
Description 
Unrelated 
AE is clearly not related to the 89Zr-DFO-
trastuzumab       
Unlikely 
AE is unlikely related to the 89Zr-DFO-
trastuzumab       
Possible 
AE may be related to the 89Zr-DFO-
trastuzumab       
Probable 
AE is likely related to the 89Zr-DFO-
trastuzumab       
Definite 
AE is clearly related to the 89Zr-DFO-
trastuzumab       
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Adverse events will be defined graded  using CTCAE V4.0.  
 
18.0 
INFORMED CONSENT PROCEDURES 
Before protocol-specified procedures are carried out, consenting professionals will explain 
full details of the protocol and study procedures as well as the risks involved to participants 
prior to their inclusion in the study. Participants will also be informed that they are free to 
withdraw from the study at any time. All participants must sign an IRB/PB-approved consent 
form indicating their consent to participate. This consent form meets the requirements of the 
Code of Federal Regulations and the Institutional Review Board/Privacy Board of this Center. 
The consent form will include the following:  
1. The nature and objectives, potential risks and benefits of the intended study.  
2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard and 
investigational therapies. In addition, patients will be offered an option of 
supportive care for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions and 
to withdraw from participation at any time.  
Before any protocol-specific procedures can be carried out, the consenting 
professional will fully explain the aspects of patient privacy concerning research 
specific information. In addition to signing the IRB Informed Consent, all patients must 
agree to the Research Authorization component of the informed consent form. 
Each participant and consenting professional will sign the consent form. The 
participant must receive a copy of the signed informed consent form. 
 
 
19.0 
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31. Scaltriti M, Rojo F, Ocana A, Anido J, Guzman M, Cortes J, et al. Expression of p95HER2, a 
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35. Matsubara J, Yamada Y, Hirashima Y, Takahari D, Okita NT, Kato K, et al. Impact of Insulin-
Like Growth Factor Type 1 Receptor, Epidermal Growth Factor Receptor, and HER2 
Expressions on Outcomes of Patients with Gastric Cancer. Clin Cancer Res. 2008;14:3022-9. 
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10.1093/annonc/mdr021. 
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20.0 
APPENDICES 
 
APPENDIX 1:  
Karnofsky Performance Status 
 
Karnofsky Performance Scale 
Condition 
% 
Comments 
Able to carry on normal activity and to work; 
no special care needed. 
  100   
Normal; no complaints; no evidence of disease. 
90 
Able to carry on normal activity; minor signs or 
symptoms of disease. 
80 
Normal activity with effort; some signs or 
symptoms of disease.  
Unable to work; able to live at home and care 
for most personal needs; varying amount of 
assistance needed. 
70 
Cares for self; unable to carry on normal activity or 
to do active work. 
60 
Requires occasional assistance, but is able to care for 
most of his personal needs. 
50 
Requires considerable assistance and frequent 
medical care.  
Unable to care for self; requires equivalent of 
institutional or hospital care; disease may be 
progressing rapidly. 
40 
Disabled; requires special care and assistance. 
30 
Severely disabled; hospital admission is indicated 
although death not imminent. 
20 
Very sick; hospital admission necessary; active 
supportive treatment necessary. 
10 
Moribund; fatal processes progressing rapidly. 
0 
Dead 
 
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IRB Number: 13-165 A(12)
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Memorial Sloan Kettering Cancer Center
IRB Number: 13-165 A(12)
Approval date: 30-Nov-2020