Study of the Effects of Dexamethasone on Non-Small Cell Lung Cancer Using [F-18] FLT for Imaging With Positron Emission Tomography (PET)
Phase: NA
Conditions: Recurrent Non-Small Cell Lung Carcinoma, Stage IIIA Non-Small Cell Lung Cancer, Stage IIIB Non-Small Cell Lung Cancer, Stage IV Non-Small Cell Lung Cancer
Sponsor: Barbara Ann Karmanos Cancer Institute

 1
PROTOCOL # 2015-174 
2/4/16; Revised 8/11/16; Revised 11/14/18; Revised 4/11/19  
 
WAYNE STATE UNIVERSITY SCHOOL OF MEDICINE 
Karmanos Cancer Institute 
 
 
# 2015-174:  STUDY OF THE EFFECTS OF DEXAMETHASONE ON NON-SMALL CELL LUNG 
CANCER USING [F-18] FLT FOR IMAGING WITH POSITRON EMISSION TOMOGRAPHY 
(PET) 
 
FAST FACTS ........................................................................................................................................................ 2 
I. OBJECTIVES .................................................................................................................................................... 4 
II. BACKGROUND .............................................................................................................................................. 4 
III. PATIENT SELECTION ................................................................................................................................ 8 
IV. REGISTRATION PROCEDURES ............................................................................................................ 8 
V. TREATMENT PLAN ...................................................................................................................................... 9 
VI. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS ............................................ 10 
VII. MEASUREMENT OF EFFECT: FLT-PET SCANS ........................................................................ 12 
VIII. CORRELATIVE STUDIES .................................................................................................................... 13 
IX. STATISTICAL CONSIDERATIONS ..................................................................................................... 14 
X. DATA AND SAFETY MONITORING/STUDY AUDITS/STUDY ETHICS .................................. 15 
XI. REFERENCES ............................................................................................................................................ 17 
APPENDIX A:  STUDY SCHEMA ............................................................................................................... 20 
 
Principal Investigator:    
 
Anthony F. Shields, M.D., Ph.D.  
 313-576-8735 voice, 313-576-8767 FAX 
 E-mail: shieldsa@karmanos.org 
4100 John R Street, HW04HO 
 
Detroit, MI 48201 
 
Co-Participants: 
 
 
 
Hirva Mamdani, M.D. 
Manohar Ratnam, Ph.D.                 
 
Misako Nagasaka, M.D. 
 
Ammar Sukari, M.D. 
 
Ulka Vaishampayan, M.D.          
 
Amy Weise, D.O.    
 
Salman Fateh, D.O. 
 
Frank Knechtl, D.O. 
 
Paul Porter, M.D. 
 
Rana Bilbeisi, M.D.                               
 
Seraphim Pallas, M.D. 
 
Anteneh A. Tesfaye, M.D.  

 2 
Larry Matherly, Ph.D.                      
Thomas Mangner, Ph.D.                 
 
Laurel Stroempl, P.A.-C          
Wei Chen Ph.D., Biostatistician 
Seong Ho Kim, Ph.D., Biostatistician 
Courtney French, PA-C 
Kimberly Belzer, P.A. 
Mary Ann Schwartz, N.P.  
Prahlad Parajuli, Ph.D., Tumor Immunologist 
Rayna Rosati, Ph.D., Postdoctoral Fellow               
FAST FACTS 
 
Objectives 
The purpose of this study is to assess the effect of the corticosteroid dexamethasone (Dex) in patients 
with non-squamous Non-Small Cell Lung Cancer (NSCLC). This will be conducted using 3’-
fluorothymidine (FLT) positron emission tomography (PET) done under ongoing imaging protocol 2006-
127. The principal objective will be to compare tumor maximum, mean and peak standardized uptake 
values (SUVmax, SUVmean and SUVpeak), at baseline and after Dex treatment using FLT-PET 
imaging under ongoing imaging protocol 2006-127.  
 
Correlative Studies 
1. Patients will undergo three FLT-PET scans:  
i. 
Scan 1: Before Dex treatment, for a baseline 
ii. 
Scan 2 either on day 3 or 13-14 of Dex: Image patients on Dex 4 mg bid to assess anti-
proliferative effect. Patients will continue Dex for 14 days total to evaluate the effect on 
senescence and then stop Dex for 7 days.   
iii. 
Scan 3 after discontinuation of prolonged Dex treatment: Treat patients for 14 days with 
Dex and then stop for about 7 days (day 6-8) and reimage the patients determine if Dex 
induces irreversible senescence when given for 14 days. 
2. Tumor Glucocorticoid Receptor α expression (GRα) will be assessed from tumor tissue, pre-
treatment obtained for initial diagnosis and as part of routine care.  
3. Blood samples will be collected at the time of each imaging to measure serum Dex 
concentration and T cell, NK cell and monocyte cell counts and activation status and, plasma 
senescence markers as described below. 
 
Key Inclusion/Exclusion Criteria 
1. Patients must have histologically or cytologically proven non-squamous NSCLC. Patients may 
have newly diagnosed, recurrent, progressive or refractory or non-refractory disease which may 
be localized or wide spread. 
2. Measurable disease with at least one lesion  >2 cm on CT/MR. 
3. No chemotherapy for at least 4 weeks and no radiation to the index lesion or clear progression 
in previously radiated lesion (greater than 20% increase in longest diameter). 
4. Must be able to undergo three FLT-PET scans and sign consent for this protocol and FLT-PET 
protocol 2006-127.  
 
Treatment Plan 
 
Pre-study history, performance status, physical examination, and blood tests within 6 weeks 
period before the start of the study.  A blood pregnancy test may be needed for females of 
childbearing potential. As described in the patient consent form. 
 
Scan 1: Baseline FLT-PET within 7 days prior to the start of Dex treatment. 
 
Oral Dex 4 mg twice daily  

 3 
 
Scan 2: Either on day 3 or 13-14 of Dex. 
 
Continue oral Dex 4 mg twice a day for a total of 14 days 
 
Scan 3: about 7 days (day 6-8) after the final dose of Dex. 
 
After Scan 3: Dex 4 mg twice daily (chronic Dex) may resume based on treating physician’s 
discretion.  
 
Prominent Adverse Effects 
 
Dexamethasone: Headache, Nausea, Increased blood pressure, Mood changes, Increased 
susceptibility to infection.  
 
Correlative Markers: 
 
GRα expression in tumor tissue will be measured from the most recent tumor sample available 
using either one or both of 1) optimized TaqMan probes to quantify GRα mRNA; and 2) semi-
quantitative immunohistochemistry to measure GR protein.   
 
Blood (5 ml) drawn at the time of each scan will be used to prepare serum which will be frozen 
for analysis of Dex levels. 
 
Additional blood samples (15 ml) drawn at each scan will be used for the following analyses:  
 
Measurement of T cell, monocyte and NK cell numbers and activation status by multi-parametric 
flow cytometry  
 
Measurement of various plasma cytokines and chemokines which will include, CCL2 (MCP-1), 
CCL4(MIP-1b), CXCL1 (GROa) and CXCL2 (GROb) using a multiplex cytokine array.    
 
 
In summary, blood will be obtained at baseline, at every scan and 7-15 days after patients are 
started on chronic Dex treatment in patients wishing to continue on therapy. 
 
 

 4 
I. OBJECTIVES 
 
1. Primary Objective: The primary objective of this pilot study is to evaluate the effect of 
dexamethasone (Dex) treatment in patients with non-squamous Non-Small Cell Lung Cancer 
(NSCLC) using 3’-fluorothymidine (FLT) positron emission tomography (PET) as measured by 
changes in tumor maximum standardized uptake value (SUVmax), SUVmean and SUVpeak. 
2. Secondary Objectives: 
i. 
Measure tumor Glucocorticoid Receptor α expression (GRα) from tumor tissue, when 
available.    
ii. 
Analyze blood samples obtained during imaging to determine:  
a. serum Dex concentration  
b. counts and activation status of peripheral blood mononuclear cells 
c. plasma levels of cytokines and chemokines associated with tumor senescence 
 
  
II. BACKGROUND 
 
1. Non-Small Cell Lung Cancer 
Lung cancer is the leading cause of cancer-related mortality in the United States, accounting for 
approximately 27% of cancer deaths (1). Over 80% of lung cancer patients have non-small cell lung 
cancer (NSCLC), the majority of whom present with advanced disease. NSCLC patients face an 
overall 5-year survival rate of only 18%, which falls to 4% in patients with metastatic disease. 
Current first-line treatment decisions for advanced non-squamous NSCLC are based on the 
presence of targetable genetic aberrations, such as sensitizing mutations of EGFR, BRAF, and 
MET, or translocations of  ALK and ROS1 genes. However, these oncogenic drivers are present 
in only up to 20% of patients, and for rest of the patients, treatment options include the PD-1 
inhibitor pembrolizumab either alone or in combination with platinum-pemetrexed chemotherapy 
(2, 3). The advent of immune checkpoint inhibitors has brought a paradigm shift in the 
management of advanced non-small cell lung cancer (NSCLC) with more than 2-fold 
improvement in median overall survival (mOS) in a subset of patients. However, inevitable 
development of resistance to these agents with eventual disease progression is a challenge. 
Therefore, novel treatment options are urgently needed.  
 
2. Dexamethasone  
As standard practice, patients undergoing pemetrexed-based chemotherapy are administered 4 mg 
of Dex twice daily starting the day before therapy and continuing until the day after treatment (4). 
The purpose of Dex in this context is to reduce the possibility of severe (grade 3 and 4) skin rash 
associated with pemetrexed therapy. In addition, Dex is frequently used as an anti-emetic for 
patients receiving combination therapy with cisplatin or carboplatin (5). The pharmacological actions 
of Dex are mediated by the glucocorticoid receptor (GR), which functions principally as a 
transcription factor (6). Regulation of gene expression by glucocorticoids produces a myriad of 
profound, tissue-specific cellular events (7). Glucocorticoid signaling controls cell proliferation and 
apoptosis, as well as inflammation and the inflammatory response (8, 9). The nature of the 
physiological response, as well as sensitivity to synthetic glucocorticoids such as Dex, is variable 
and tissue-dependent (10).  
 
In cancer cells, glucocorticoids can modulate cell growth, cell survival and cellular senescence in a 
cell type-specific fashion (11-13). Several studies have indicated that, unfortunately, Dex may 
attenuate the anti-neoplastic effects of the chemotherapy whose side effects it is being used to 
alleviate (13-16). This effect has been shown to occur by distinct mechanisms, depending on the 
type of tumor. In triple-negative breast cancer cells, for example, Dex strongly activates pro-survival 
signaling (14-16). Recent work in NSCLC cells has reported that Dex produces reversible arrest of 
tumor cells in the early G1 phase of the cell cycle, rendering the cells resistant to pemetrexed (13). 

 5 
Moreover, Dex treatment decreases expression of the reduced folate carrier and proton-coupled 
folate transporter, the major transporters of pemetrexed into the cell. Our research in clinically 
relevant NSCLC cell lines including loss- and gain-of-function studies has demonstrated that GRα 
expression is the principal determinant of the ability of Dex to protect NSCLC cells against 
pemetrexed (13). An analysis of GRα in advanced NSCLC tumors found that there is an 
approximately equal distribution of tumors with high and low GR expression (17).  
 
In contrast to the above reversible effects of administering Dex for relatively short durations (24 h – 
72 h), recent studies have demonstrated that in cells with glucocorticoid receptor-α (GR) expression 
corresponding to higher clinical tumor levels, extended (2 weeks) treatment with Dex induced a 
senescence phenotype (18). Under these conditions, the initial Dex-induced growth arrest was 
followed by marked cell expansion, beta-galactosidase expression and Ki67 negativity, regardless 
of p53 and K-RAS status. Dex induced a transient early surge in p21Cip1. However, a progressive, 
irreversible loss of clonogenic growth, whose time of onset was dependent on GR level and Dex 
dose, was independent of p21Cip1and caused by gradual accumulation of p27Kip1 due to 
transcriptional activation of p27Kip1 by Dex. This effect was independent of canonical pathways of 
senescence or p27Kip1 regulation. The in vitro observations were reflected by growth suppression 
and P27Kip1 induction in GR-overexpressing tumor xenografts compared with isogenic low-GR 
tumors.  
 
Further unpublished studies have shown that induction of senescence by Dex was accompanied in 
high GR expressing lung adenocarcinoma cells by the release of select chemokines, including 
CCL2 (MCP-1), CCL4(MIP-1b), CXCL1 (GROa) and CXCL2 (GROb). The production of these 
cytokines continued even after withdrawal of Dex. Paracrine effects of the Dex treated cancer cells 
induced migration of monocytes, NK cells and T cells, expansion and activation of NK cells, tumor 
cell cytolytic activity in NK cells, a modest reduction in MHC Class I expression, increase in MIC-
A/B expression and PBL cytotoxicity. 
 
Even in patients who received Dex prior to potentially curative surgery may benefit from Dex 
treatment, as shown in a recently published study(19).   588 patients with a median follow-up 
duration of 5.2 years, were found to have improved survival based on more complete resection, 
smaller tumor size, and highly differentiated tumors. Furthermore, perioperative use of 
dexamethasone was associated with long survival (HR, 0.70; 95% CI, 0.54–0.90; P = .006). 
 
In summary, extended Dex treatment induces irreversible cell cycle blockade and a senescence 
phenotype through chronic activation of the p27Kip1 gene in GR overexpressing lung tumor cell 
populations. The Dex responsive tumor cells secrete chemokines that attract immune cells and 
activate a response against the tumor cells. Hence, extended Dex treatment of high GR expressing 
tumors could improve outcome of surgery/pemetrexed chemotherapy and sensitize tumors to 
immunotherapy. 
   
Pharmacokinetic Data 
The pharmacokinetics of Dex has been well characterized in humans as well as animal models. 
Dex has been shown to have an oral bioavailability of 70-80% (20). Although the plasma half-life of 
Dex is 3.5-4.5 hours, the pharmacological effects of Dex significantly outlast its plasma 
concentration due to significant (up to 77%) plasma protein binding. The biological half-life has 
been found to be 36-54 hours, which has made Dex suitable for medical conditions requiring 
continuous glucocorticoid action. There is a high uptake of Dex by the liver, kidney, and adrenal 
glands. Metabolism in the liver is slow via CYP3A4 and excretion is principally renal, as 
unconjugated steroids.  
 
Safety Information 
Dexamethasone is a steroid drug that is indicated for a variety of medical uses including 
inflammatory conditions, cancer, and hormonal disorders. Dex has been approved for use in 

 6 
humans and a thorough understanding of its side effects has been established. Dosages of up to 20 
mg are routinely used in cancer patients undergoing chemotherapy to prevent nausea and vomiting, 
allergic reactions and rashes. Dex is also given long term in patients with brain metastases to 
decrease inflammation. Finally, in a randomized trial, Dex (4 mg twice daily) was shown improve 
quality of life and cancer related fatigue in patients with advanced cancer who were no longer 
receiving chemotherapy (21). 
 
Side effects of dexamethasone could include: irritation or stomach ulcers; increased blood sugar; 
hypertension; increased susceptibility to infection; and acne. More uncommon side effects that have 
been reported include: skin rash, itching or hives; swollen face, lower legs, or ankles. (See Section 
VI: Adverse Events: List and Reporting Requirements for more information).  
 
3. Status of Clinical PET Imaging in Lung Cancer and Studies of FLT-PET 
PET is now routinely used with fluorodeoxyglucose (FDG) for the diagnosis and staging of lung 
cancer, but monitoring treatment response by PET is still not part of regular assessment (22). Multi-
center trials, including ACRIN 6678 and MK-0646-008 are working to determine the sensitivity of 
FDG-PET early in the course of lung cancer therapy, and have recently published reproducibility of 
FDG-PET in NSCLC (23). FLT-PET has been shown to provide reproducible measurement of tumor 
proliferation in patients with NSCLC (24). Further, several small trials have shown FLT-PET to be 
useful in evaluating treatment response in lung cancer. One study found early FLT to be predictive 
of progression-free survival (HR, 0.31; 95% CI, 0.10 to 0.95; P < 0.05) but not overall survival in 
patients treated with erlotinib (25, 26).  
 
An ECOG-ACRIN multi-center trial of FLT-PET to assess response to neoadjuvant chemotherapy 
was conducted in breast cancer in which 51 patients underwent FLT-PET imaging at baseline, and 
following one cycle of treatment. The percent change in tumor maximum standardized uptake value 
(ΔSUVmax) between scans was calculated. Chemotherapy led to a significant ΔSUVmax (mean, 
36%; 95% CI, 28-45%) and an area under the curve for ΔSUVmax in the prediction of pathologic 
complete response (pCR) = 0.68. The best ΔSUVmax cut-off for predicting pCR was 51% 
(sensitivity 56%; specificity 79%). The difference in ΔSUVmax between patients with and without 
pCR was significant (20%; one-sided p=0.045).  
 
4. Imaging Dexamethasone Activity with FLT-PET in NSCLC  
An ongoing pilot study at the Karmanos Cancer Institute is currently examining the effect of Dex in 
patients with NSCLC using FLT-PET. Thus far, 2/4 patients scanned have shown marked 
reductions in tumor FLT retention after Dex treatment (-64.7% and -54.3%). Of interest, patients 
had variable changes in FLT retention between lesions, indicating that FLT-PET may be able to 
detect the effect of Dex in lung cancer and assess differences in GR expression across metastases. 
In this protocol, we will seek to further investigate this phenomenon, and to characterize its 
reversibility following the withdrawal of Dex treatment.    
 
5. Experimental Rationale  
Despite the emergence of newer treatment strategies including immune checkpoint inhibitors and 
targeted agents, the 5-year overall survival for advanced NSCLC patients remains poor.  Only a 
small fraction of patients achieve prolonged responses to immune checkpoint inhibitors (27). 
Furthermore, development of resistance to currently available treatment is an enormous challenge. 
Therefore, it is imperative that novel treatment strategies and therapeutic targets can be identified 
to improve outcomes of NSCLC.  
 
Recent data has demonstrated that Dex, in a GRα-dependent manner, causes reversible G1 arrest 
as well down-regulation of the major transporters and targets of pemetrexed in a subset of NSCLC 
cell models (13). Critically, these effects are associated with a profound protective effect from the 
cytotoxic effect of pemetrexed, particularly when tumor cells are pre-treated for 24 hours with Dex, 
a schedule similar to that which is used clinically. Furthermore, data from a pilot in patients with 

 7 
advanced NSCLC indicate that the effects of Dex on cell cycle progression within NSCLC tumors 
may be monitored by FLT-PET imaging. Relative expression of GRα has been found to be the 
primary determinant of variability in the Dex response among NSCLC cells, and analyses of GRα 
expression in primary lung tumors have reported tumor levels of GRα to be highly variable (17).  
 
Despite the rapid systemic clearance of pemetrexed, cellular retention of pemetrexed as a result of 
its metabolism to polyglutamates confers a special advantage to pemetrexed-based chemotherapy 
(28). Both reduced polyglutamylation of pemetrexed and increased degradation of polyglutamate 
chains have been associated with pemetrexed resistance (29). In the clinical setting, clearance of 
Dex is relatively slow, with pharmacologically effective concentrations remaining in circulation for 
several days following administration (30). These and additional considerations including the fact 
that patients also receive Dex the day after pemetrexed; it takes a further 12-24 hours for the tumor 
cells to re-enter S-phase after Dex has been cleared; decreased pemetrexed uptake by RFC and 
PCFT occurs after Dex treatment, suggest that Dex-sensitive NSCLC tumors will be less 
responsive to pemetrexed when given with a standard Dex regimen prior to chemotherapy.  
 
Stratifying patients on the basis of Dex sensitivity (or pemetrexed resistance) by FLT-PET imaging 
and/or by evaluating tumor GRα status may not only help to avoid subjecting predicted non-
responders to futile treatment cycles, but could allow the clinical oncologist to switch to a potentially 
more useful regimen. Indeed, patients with high GRα tumors may respond better to alternative 
chemotherapies that require limited Dex treatment or no Dex at all (e.g. nab-paclitaxel instead of 
paclitaxel). Given the high degree of patient variability to response to pemetrexed, strategic 
treatment decisions would be expected to improve the treatment of tens-of-thousands of patients 
per year.  
 
More recent studies have demonstrated that Dex-induced tumor cell senescence may be utilized as 
a potential treatment strategy, either by itself or in combination with other treatment modalities, for 
GRα expressing NSCLC. Thus in lung adenocarcinoma tumors expressing relatively high levels of 
GR (about a third to a half of all lung adenocarcinoma lesions), extended (2 weeks) Dex treatment 
may be expected to cause irreversible cell cycle blockade in the pemetrexed-resistant tumor cell 
population as well as sensitization of the entire tumor to immune attack. These events during 
extended Dex administration could be established and monitored in the patients through a 
combination of 1. FLT-PET imaging of individual lesions to monitor both initial effects of Dex on 
tumor cell proliferation and effects following Dex withdrawal and 2. Correlative blood tests to 
evaluate production of tumor senescence associated chemokines and immune activation post-Dex 
treatment.   FLT-PET will allow us to make such measurements non–invasively and assess 
heterogeneity between patients and across multiple lesions in a single patient. 
 
In summary, based on the rationale that 
1. Pemetrexed-based regimens that are the standard-of-care in advanced NSCLC include Dex 
treatment on the day before, day of, and day after pemetrexed administration.  
2. Dex, in a GRα -dependent manner, has been shown to reversibly inhibit NSCLC cell 
progression into the S-phase of the cell cycle, producing down-regulation of pemetrexed 
transporters and target enzymes, and resulting in a protection of NSCLC cells from 
pemetrexed cytotoxicity.  
3. Primary NSCLC tumors are highly variable in their expression of GRα. 
4. Extended (2 weeks) Dex treatment induces irreversible cell cycle blockade and a 
senescence phenotype through chronic activation of the p27Kip1 gene in GR 
overexpressing lung tumor cell populations 
5. Induction of senescence by Dex is accompanied in high GR expressing lung 
adenocarcinoma cells by the release of select chemokines that attract and activate T cells, 
NK cells and monocytes and tumor cell cytolytic activity of NK cells 
6. Pilot data that show FLT-PET is able to monitor Dex-mediated G1 arrest in patients with 
advanced lung cancer.  

 8 
 
This arm of our pilot study will evaluate the effect of Dex in patients with NSCLC using FLT-PET 
imaging. This study will examine whether FLT-PET can accurately monitor Dex-mediated S-phase 
suppression in patient tumors and whether it could be routinely employed for the stratification of 
patients by GRα status. We will conduct correlative studies to measure the reversibility of Dex 
effects in NSCLC cells and will correlate measurements of tumor GRα expression with our findings 
from FLT-PET imaging when adequate sample is available. Additional correlative studies will utilize 
patient blood samples to measure Dex levels and will look for tumor senescence markers including 
specific cytokines and for activation of immune cells. 
 
 
III. PATIENT SELECTION 
 
Eligibility Criteria 
1. Patients must have histologically or cytologically proven newly diagnosed, recurrent, 
progressive, refractory or non-refractory non-squamous NSCLC, which may be localized or 
widespread. 
 
2. Patients must have measureable disease, defined as at least one lesion that can be accurately 
measured in at least one dimension (longest diameter to be recorded) as ≥20 mm with 
conventional techniques (CT, MR or PET). Lesions in the previously irradiated area can be 
considered as measureable lesions as long as there has been an increase of at least 10 mm 
when compared to measurements obtained after completion of radiation.  
 
3. No chemotherapy for at least 4 weeks and no radiation to the index lesion or clear progression 
in that lesion (greater than 20% and at least 10mm increase in longest diameter). 
 
4. Life expectancy of greater than 4 weeks.  
 
5. Absolute neutrophil count ≥1,000/mcL (measured within 6 weeks of registration). 
 
6. No history of HIV or active infections. 
 
7. Random blood glucose of ≤300mg/dl if history of diabetes mellitus. . 
 
8. No surgery in the last 2 weeks prior to study enrollment. 
 
9. Has not received Dex or another corticosteroid in over 4 weeks prior to enrollment. 
 
 
 
10. Ability to understand and the willingness to sign a written informed consent document. 
 
11.  Agreed to FLT-PET imaging and signed consent and eligible FLT-PET protocol 2006-127. 
 
 
IV. REGISTRATION PROCEDURES  
 
General Guidelines 
Eligible patients will be entered on the study centrally at the clinical trials office of the Karmanos Cancer 
Center/Wayne State University by the study coordinator.  
 
At the time of registration: 
 
Patients must have signed an informed consent form.  

 9 
 
Confirm that all required prestudy history and physical examination, and laboratory tests have 
been collected.  
 
Document demographic information including smoking history. Also document medications.  
 
Patients should be scheduled for pre-treatment FLT-PET scans if patients have provided 
appropriate consent.  
 
Previous tumor biopsy should be retrieved for GRα analysis. This is not required prior to the 
start of therapy but should be retrieved within a month of registration.  
 
Inform patients about all necessary follow-up including laboratory tests and further PET imaging.  
 
Following registration, patients should begin protocol treatment within 7 days. Issues that would cause 
treatment delays should be discussed with the Principal Investigator, Dr. Anthony Shields at 313-576-
8735; shieldsa@karmanos.org, or contact the study coordinators. If a patient does not receive protocol 
therapy following registration, the patient’s registration on the study may be cancelled. The study 
coordinator should be notified of cancellations as soon as possible.  
 
Registration Process 
To register a patient, the following documents should be completed by the research nurse or data 
manager and faxed or emailed to the study coordinator: 
 
Copies of required laboratory tests, scans.  
 
Signed patient consent form. 
 
HIPAA authorization form. 
 
Eligibility checklist. 
 
Completed registration form. 
 
To complete the registration process, the study coordinator will: 
 
Register the patient on the study. 
 
Contact the research nurse or data manager and verbally confirm registration.  
 
Off-Study Criteria 
 
Patients will be considered to have gone off of study following the completion of the third FLT-
PET scan unless they elect to continue Dex therapy under the supervision of their physician. 
 
Patients continuing Dex (chronic Dex) will remain on study until Dex treatment has been 
discontinued.  
 
 
V. TREATMENT PLAN 
 
FLT-PET Imaging 
 
Scan 1: Baseline within 7 days prior to the start of Dex treatment. 
 
Scan 2: Either on day 3 or 13-14 of Dex. 
 
Scan 3: Continue oral Dex 4mg twice a day for a total of 14 days, then stop Dex and obtain 
Scan 3 6-8 days after the final dose of Dex. 
 
Agent Administration 
Treatment will be administered on an outpatient basis. Reported adverse events and potential risks for 
Dexamethasone are described in Section VI. No investigational or commercial agents or therapies 
other than Dexamethasone may be administered with the intent to treat the patient’s malignancy.  
 
AEs will be collected at the time of consent, at each scan and until Dex is discontinued.  Patients 
electing to continue on chronic Dex will be followed by their treating physician. 
 
 

 10
Agent 
Dose 
Route 
Schedule 
 
Dexamethasone 
4 mg 
Orally 
Twice daily for a total of 14 days. Scans before, 
during Dex as directed on day 3 or 13-14 and 6-8 
days after Dex. 
 
 
*Patients may elect to stay on dexamethasone (4 mg bid) indefinitely following the completion Scan 3 if 
it is considered to provide benefit by their treating physician.  Patients continuing on Dex (chronic Dex)  
will be followed by the treating physician. 
 
Benefits: 
Dex 4mg twice daily compared to placebo has been shown to improve cancer related fatigue, anorexia 
and quality of life in patients with advanced cancer (22). 
 
Correlative Markers: 
1. GRα expression in tumor tissue will be assessed from the most recent tumor tissue available,  using 
Either one or both of 1) optimized TaqMan probes to quantify GRα mRNA; and 2) semi-quantitative 
immunohistochemistry to measure GRα protein. The Biobanking and Correlative Sciences (BCS) 
Core facility at KCI will perform immunohistochemical studies on fixed tumor tissue under the 
supervision of Dr. Julie Boerner, the director of the BCS Core. The BCS Core will assist with the 
acquisition of patient tissue as well as preparation of samples for analysis. Analyses of GRα mRNA 
will be conducted in the Ratnam Laboratory at in the Hudson-Webber Cancer Research Center and 
will be under the direct supervision of Dr. Manohar Ratnam.  Testing will be prioritized depending 
on the amount of sample available as follows: 
i. 
approximately 5000 cells or more:  TaqMan probes to quantify GRα mRNA 
ii. 
approximately 5 cells:  immunohistochemistry to measure GRα protein 
 
2. Blood (20 ml) will be drawn at the time of each scan specifically, by the personnel at the Children’s 
Hospital of Michigan PET Center. 15 ml of blood will be placed in heparinized tubes whereas serum 
will be prepared from the remaining 5 ml of blood.  
i. 
The serum samples will be used for analysis of Dex levels and to measure levels of specific 
chemokines. Serum samples will be taken to the KCI Pharmacology Core facility and frozen.  
The concentration of Dex will be measured using liquid chromatography-mass spectroscopy. 
Dr. Jing Li, the director of the KCI Pharmacology Core facility, will oversee quantification of 
plasma Dex concentration. Dr. Ratnam’s lab will measure cytokine levels in the serum. 
ii. 
The 15 ml of whole blood will be transported to the Ratnam lab for flow cytometric analysis 
of immune cells.  
 
 
VI. ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS  
 
This study will use the descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All appropriate 
treatment areas should have access to a copy of the CTCAE version 4.0. A copy of the CTCAE can be 
downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40).  
 
Reporting Adverse Events 
In the unlikely event that any immediate toxicity is found during the course of treatment, it will be 
recorded and reported as described below. Given the dose of drug, no measurable delayed toxicity is 
expected.  
 
 
 

 11
 
 
Reaction 
 
 
 
 
Reporting Obligation for A, B, and C 
 
 
 
A. All life-threatening events      
 
           Within 24 hours  
 
 
(Grade 4), which may be due to drug 
 
[Note 1] 
 
 
Administration [Note 2] 
 
 
 
 
 
B. All fatal events (Grade 5) while on  
 
Written report to follow within  
 
 
study (or within 24 hours of treatment). 
 
10 working days. [Note 3] 
 
 
 
C. First occurrence of any previously 
 
[Notes 4 and 5] 
 
 
unknown clinical event (regardless of grade). 
 
Note 1  
Telephone number available 24 hours daily: (301) 230-2330 (Recorder after hours). 
Note 2  
See DCTD/NCI Common Terminology Criteria for Adverse Events. 
Note 3  
Report to: Investigational Drug Branch, PO Box 30012, Bethesda, MD, 20824. 
Note 4             A list of all known toxicities can be found in the protocol document or consent form. 
Note 5  
Reactions judged definitely not treatment-related should not be reported.  
 
 
Information about all adverse events, whether volunteered by the subject, discovered by 
investigator questioning, or detected through physical examination, laboratory test or other 
means, will be collected and recorded on the Adverse Event Case Report Form and followed as 
appropriate. An adverse event is any undesirable sign, symptom or medical condition occurring 
after starting even if the event is not considered to be related.  
 
 
Medical conditions/diseases present before starting study treatment are only considered 
adverse events if they worsen after starting study treatment (any procedures specified in the 
protocol).  
 
 
Any serious adverse event occurring after the patient has provided informed consent and until 4 
weeks after the one dose of Dex must be reported. 
 
 
Adverse events occurring before starting study treatment but after signing the informed consent 
form are recorded on the Medical History/Current Medical Conditions Case Report Form.  
 
 
Abnormal laboratory values or test results constitute adverse events only if they induce clinical 
signs or symptoms or require therapy, and are recorded on the Adverse Events Case Report 
Form under the signs, symptoms or diagnosis associated with them.  
 
Adverse Event (AE) Characteristics  
 
Serious adverse events  
A serious adverse event is an undesirable sign, symptom or medical condition which:  
1. Is fatal or life-threatening.  
2. Required or prolonged hospitalization  
3. Results in persistent or significant disability/incapacity  
4. constitutes a congenital anomaly or a birth defect  
5. are medically significant, may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed above  
 
Not considered to be serious adverse events are hospitalizations for the:  
1. Routine treatment or monitoring of the studied indication, not associated with any deterioration 
in condition.  
2. Treatment, which was elective or pre-planned, for a pre-existing condition that did not worsen  

 12
3. treatment on an emergency, outpatient basis for an event not fulfilling any of the definitions of 
serious given above and not resulting in hospital admission 
  
Commonly Reported Side Effects of Dexamethasone 
 
Stomach upset, irritation or stomach ulcers 
 
Increased blood sugar 
 
Increased blood pressure and swelling from fluid retention 
 
Decreased production of cortisol 
 
Increased susceptibility to infection 
 
Insomnia 
 
Mood changes, depression, anxiety 
 
Restlessness 
 
Vomiting 
 
Diarrhea 
 
Fever 
 
Decreased platelet count 
 
Increased risk of cataracts and glaucoma 
 
Osteoporosis 
 
Muscle loss 
 
Problems with healing 
 
Acne 
 
Weight gain 
 
Easy bruising 
 
Irregular or absent menstrual periods. 
 
Headache 
 
Dizziness 
 
Increased hair growth  
 
Serious Side Effects Requiring Medical Attention 
 
Skin rash, itching, or hives 
 
Swollen face, lower legs, or ankles 
 
Vision problems 
 
Black or tarry stool 
 
Loss of consciousness 
 
Difficulty breathing 
 
Difficulty swallowing   
 
‘Attribution’ of the AE will be defined by the investigative team  
 
Definite – The AE is clearly related to the study treatment  
 
Probable – The AE is likely related to the study treatment  
 
Possible – The AE may be related to the study treatment  
 
Unlikely – The AE is doubtfully related to the study treatment  
 
Unrelated – The AE is clearly NOT related to the study treatment  
 
 
VII. MEASUREMENT OF EFFECT: FLT-PET SCANS 
 
FLT-PET scans will be performed and data will be collected and analyzed as described in protocol 
2006-127. 
 
[18F]-FLT [3’-deoxy-3’-18F-fluorothymidine] is a thymidine analog used in PET imaging. After transport 
into the cells, it is phosphorylated by TK1 and trapped intracelluarly. Due to the lack of a 3’ hydroxyl 

 13
group on its sugar, it cannot incorporate into the DNA structure, and therefore its retention reflects 
intracellular TK1 (31-33). FLT accumulates in tissues with high expression of TK1, such as bone 
marrow and tumors, and is a proliferation-imaging tracer (31, 33, 34). Kinetics data has shown that FLT 
is useful as a predictor of response to therapy in lung cancer (35). 
 
FLT was originally developed for the treatment of HIV infection (36). In the initial human trial a starting 
dose of 0.125 mg/kg q12 hours resulted in grade 3 hematologic toxicity in 6/10 subjects. Other 
cytopenias have also been noted. The dose to be given during FLT-PET scans is about 0.02 mg or 
<1% of the dose used in the initial trials. Toxicity took weeks to develop even at the high therapeutic 
doses used in the phase I study. Based on this work no toxicity is anticipated as part of these imaging 
studies. In the unlikely event that any toxicity is found it will be recorded and reported. 
 
PET imaging will be conducted over 60 minutes after the injection of approximately 10 mCi or tracer, 
once before therapy, and twice after the Dex administration. The first scan will be within 7 days prior to 
the start of Dex treatment 4 mg twice daily. The second scan will be during Dex, on day 3 or 13-14. The 
third and final scan will be done 6-8 days after the final Dex treatment.   
 
Data Collection  
Tumor uptake will be measured as Standard Uptake Value (SUV). SUV is calculated by the following 
formula: 
 
SUV = Radioactivity concentration in ROI (μCi/mL) / Injected Dose (mCi) / Body Weight (kg) 
 
The Standard Uptake Value maximum (SUVmax) will measure the most active pixel in the tumor and 
the two adjacent planes. Regions of Interest (ROIs) for the SUVmean will be drawn using isocontours 
set at 50% of the SUVmax.  Results will be indicated as percent change in the uptake between the two 
scans. A pilot study of FLT-PET in NSCLC has shown that the measurement of SUVmean is 
reproducible in untreated patients, with errors of <10% when imaged twice within one week (24).  
SUVpeak considers the variation within a tumor.  ROIs for the SUVpeak may be drawn with variations 
such as changing size, location and shape of the ROI. Results will be indicated as an average over a 
circle of approximately 1 cm around the hottest pixel and averaged over three adjacent or consecutive 
planes.   One study of FLT-PET in solid tumors has shown that intratumor variations caused minimal 
variations in average tumor response but depending on how the ROI was drawn may be indicative of 
tumor response (37). 
 
Analysis and Interpretation of Results 
SUVmean will show the average standard uptake in the region of interest of the tumor and is 
representative of the total tumor uptake. Comparison between SUVmean in scans before and after 
therapy allows for measurements of the effect of treatment on the whole tumor tissue. Conversely, 
SUVmax will show the highest uptake in the selected region of interest of the tumor and will allow for 
comparisons of the effect of therapy within the most active sites of the tumor.  The difference in 
SUVpeak between scans will be determined.  SUVpeak may be an indication of tumor response with 
intratumoral measurements in scans before and after therapy.  
 
 
VIII. CORRELATIVE STUDIES  
1. Tumor GRα expression in tumor tissue obtained from the most recent tumor sample available, 
when sample size is adequate. 
As discussed above, GRα status is the principal determinant of the sensitivity of NSCLC to 
suppression of the S-phase of the cell cycle by Dex (13). As such, FLT-PET imaging studies will be 
correlated to patient specimens when available to verify that the imaging method is providing results 
consistent with cellular signaling within tumors. GRα will be measured using either 1)  optimized 
TaqMan probes to quantify GRα mRNA or 2) semi-quantitative immunohistochemistry to measure 

 14
GR protein.  GRα expression by stain requires approximately 5 cells while TaqMan needs 
approximately 5000 or more.  Consideration for each sample size will determine which correlative 
studies will be done.  If GRα is negative on the first sample then testing subsequent samples is not 
indicated. 
 
As detailed above, the Ratnam laboratory will be responsible for measurements of GRα mRNA 
levels and the BCS core will conduct immunohistochemistry on fixed patient biopsy samples.  
 
2. Measurements of blood Dex levels. 
Of a total of 20 ml of blood drawn at the time of each FLT-PET scan, 5 ml will be used to generate 
serum. A part of the serum will be used for analysis of Dex levels using LC-MS. As mentioned, 
these experiments will be carried out at the KCI Pharmacology Core facility.  
 
3. Measurements of tumor senescence markers and immune cell status 
In addition to its anticipated effects on FLT-PET imaging, extended dexamethasone treatment has 
been shown to induce cellular senescence in cells expressing very high-level GR resulting in 
secretion of chemokines (senescence markers) in the plasma that in turn activate immune cells. 
The correlative studies will focus on the senescence markers and T cell and NK cell frequency 
(proliferation) and activation profile during long-term Dex treatment compared with the pre-
treatment samples.  
 
Peripheral blood (20 ml) will be drawn at the following time points: (1) Pre-treatment; (2) At scan 3 
on Day 3 or 13-14 of Dex treatment and 1 week (6-8 days) after stopping Dex treatment. 5 ml of the 
blood will be used to prepare serum, a part of which will be used to measure Dex levels as noted 
above. The remaining serum will be used to measure levels of specific cytokines previously found 
to be sectreted by the senescent tumor cells, including CCL2 (MCP-1), CCL4(MIP-1b), CXCL1 
(GROa) and CXCL2 (GROb). 
 
Blood from blood drawn at the time of each FLT-PET scan will be collected in heparin tubes and 
plasma and PBMC will be isolated using Ficoll gradient centrifugation following a standard protocol. 
With the PBMC, multi-parametric flow cytometry will be performed for phenotypic and functional 
characterization, including activation markers, intracellular cytokine profile, of immune cell subsets, 
as follows: 
 
Surface stain: 
CD3                         
FITC                        
CD56                       
PE                            
NKG2D                  
BV510                   
 
CD16                       
APC-Cy7                
PD-1                       
BV421                    
 
Intracellular staining: 
IFN-γ                       
 BV711                    
Perforin                
AF647                     
Ki67 
 
 
PerCP-eFluor710   
 
 
IX. STATISTICAL CONSIDERATIONS  
 
Study Design 
This a small pilot study of 6 patients with NSCLC, with each patient serving as his/her own control. The 
primary goal will be to use FLT-PET to determine the change, if any, in tumor SUVmax between the 
baseline scan prior to treatment, and the second scan on day 3 or 13-14 of Dex, 4 mg twice daily. 
Comparison between SUVmax in scans before and after Dex therapy makes it possible to measure the 

 15
effect of Dex on the whole tumor tissue. In addition, patients will be imaged about 7 days after 
discontinuation of Dex and tumor senescence markers will be assessed using biopsy samples and 
blood drawn at the time of imaging.  
 
CT anatomic landmarks will be used to assess the same lesion post-treatment if the lesion is difficult to 
visualize on PET imaging. SUVmean measurements will also be recorded. The reproducibility of tumor 
uptake based on SUV analysis is estimated to be on the order of 10%, and a true effect in an individual 
case can be defined as a change in tracer uptake greater than 3 times the standard deviation (SD) of 
the tracer ([18F]-FLT) uptake without treatment.  
 
Statistical Analysis 
The primary analysis is one sample t-test for the change of SUVmax.  Secondary analyses will be 
carried out with descriptive statistics such as mean, SD, range. Correlation analysis will be descriptive.  
Spearman correlation coefficient will be calculated and scatter plot will be plotted. Subgroup analyses 
for Dex withdrawal will be performed within the GRα high group. All subgroup analyses will be 
descriptive due to the expected small sample size.   
 
Based on epidemiological studies, described previously, we expect that about 50% of patients will have 
high GRα and thus will be susceptible to Dex-mediated S-phase suppression and therefore reduced 
FLT uptake at the time of the second scan. High GRα expression, for the purposes of this protocol, will 
be measured by immunohistochemical staining and will be defined as 75% of the sections scoring 3+ or 
4+ based on a recent lung adenocarcinoma tissue microarray.   
 
Sample Size and Accrual Rate 
A sample size of 10 achieves 80% of power to detect a large effect size of 0.89 at a significance level of 
0.05 using a two-sided one-sample t test (38).  Accrual rate and study duration: We estimated the 
accrual rate at 4 patients per year but accrual may be as low as two patients per year.  The total study 
duration is expected to be 42 months including 36 months for accrual and 6 months minimum follow-up 
for primary and secondary endpoints. 
 
 
X. DATA AND SAFETY MONITORING/STUDY AUDITS/STUDY ETHICS  
 
Data and Safety Monitoring 
1. Scheduled meetings will be held monthly or more frequently depending on the activity of the 
protocol. These meetings will include the protocol investigators and research staff involved with the 
conduct of the protocol. 
2. During these meetings the investigators will discuss: 
 
Safety of protocol participants (adverse events and reporting) 
 
Validity and integrity of the data (data completeness on case report forms and complete 
source documentation) 
 
Enrollment rate relative to expectation of target accrual, (eligible and ineligible participants) 
 
Retention of participants, adherence to the protocol and protocol deviations 
 
Protocol amendments 
3. Data and Safety Monitoring Reports (DSMR) of the research meetings will be completed by the 
Study Coordinator and submitted to the Data and Safety Monitoring Committee quarterly for review.     
4. The Barbara Ann Karmanos Cancer Institute, Data and Safety Monitoring Committee (DSMC) 
provide the primary oversight of data and safety monitoring for KCI Investigator-initiated trials.   
 
 
Data Management 
Study data including patient images, biopsy slides, and blood samples will be maintained by the 
Shields’ laboratory. In addition, a KCI CTO monitor specialist will remotely essential clinical trial data. 
Frequency of monitoring will be based on accrual but will occur at least once every 2 months if a patient 

 16
has been enrolled. Monthly screening and enrollment logs will be sent to the KCI lead Study 
Coordinator.     
 
Study Audits 
Authorized representatives of FDA, a regulatory authority or Wayne State University Institutional 
Review Board (IRB) may visit the center to perform audits or inspections, including source data 
verification. The investigator should contact Clinical Trials Office immediately if contacted by a 
regulatory agency about an inspection at his center regarding this study. 
 
Ethics  
The study will be performed in accordance with ethical principles that have their origin in the 
Declaration of Helsinki and are consistent with ICH/Good Clinical Practice, applicable regulatory 
requirements.  
 
The final study protocol, including the final version of the Written Informed Consent Form, must be 
approved in writing by Wayne State University IRB. 
 
The principal investigator is responsible for informing the Wayne State University IRB of any 
amendments to the protocol. The protocol must be re-approved by the IRB annually. Progress reports 
and notifications of serious, unexpected adverse drug reactions will be provided to the IRB. The 
Principal Investigator is also responsible for providing the IRB with reports of any serious adverse drug 
reactions from any other study conducted with the investigational product.  
 
The principal investigator will ensure that the subject is given full and adequate oral and written 
information about the nature, purpose, possible risk and benefit of the study. Subjects must also be 
notified that they are free to discontinue from the study at any time. The subject should be given the 
opportunity to ask questions and allowed time to consider the information provided. In accordance with 
the Health Information Portability and Accountability Act (HIPAA), the Written Informed Consent Form 
must include a subject authorization to release medical information to Karmanos Cancer Institute, 
Wayne State University, the Detroit Medical Center, University Physician Group, or McLaren Health 
Care or Institutional Review Board access to subject’s medical information that includes all hospital 
records relevant to the study, including subjects’ medical history. 
 
The principal investigator must store the original, signed written informed consent form.  A copy of the 
signed written informed consent form must be given to the subject. 
 
 
 
 
 

 17
XI. REFERENCES 
 
1. Adler LP, Blair HF, Makley JT, Williams RP, Joyce MJ, Leisure G, Alkaisi N, Milraldi F. Noninvasive 
grading of musculoskeletal tumors using PET. J Nucl Med. 1991;32:1508-12. 
2. Reck M, Rodriguez-Abreu D, Robinson AG, Hui R, Csoszi T, Fulop A, Gottfried M, Peled N, 
Tafreshi A, Cuffe S, O'Brien M, Rao S, Hotta K, Leiby MA, Lubiniecki GM, Shentu Y, Rangwala R, 
Brahmer JR, Investigators K-. Pembrolizumab versus Chemotherapy for PD-L1-Positive Non-Small-
Cell Lung Cancer. N Engl J Med. 2016;375(19):1823-33. Epub 2016/10/11. doi: 
10.1056/NEJMoa1606774. PubMed PMID: 27718847. 
3. Gandhi L, Rodriguez-Abreu D, Gadgeel S, Esteban E, Felip E, De Angelis F, Domine M, Clingan P, 
Hochmair MJ, Powell SF, Cheng SY, Bischoff HG, Peled N, Grossi F, Jennens RR, Reck M, Hui R, 
Garon EB, Boyer M, Rubio-Viqueira B, Novello S, Kurata T, Gray JE, Vida J, Wei Z, Yang J, 
Raftopoulos H, Pietanza MC, Garassino MC, Investigators K-. Pembrolizumab plus Chemotherapy 
in Metastatic Non-Small-Cell Lung Cancer. N Engl J Med. 2018;378(22):2078-92. Epub 2018/04/17. 
doi: 10.1056/NEJMoa1801005. PubMed PMID: 29658856. 
4. Lilly E. Alimta (pemetrexed) package insert2005. 
5. Basch E, Hesketh PJ, Kris MG, Prestrud AA, Temin S, Lyman GH. Antiemetics: american society of 
clinical oncology clinical practice guideline update. Journal of oncology practice. 2011;7(6):395-8. 
doi: 10.1200/JOP.2011.000397. PubMed PMID: 22379425; PMCID: 3219469. 
6. Miranda TB, Morris SA, Hager GL. Complex genomic interactions in the dynamic regulation of 
transcription by the glucocorticoid receptor. Molecular and cellular endocrinology. 2013;380(1-2):16-
24. doi: 10.1016/j.mce.2013.03.002. PubMed PMID: 23499945; PMCID: 3724757. 
7. Kadmiel M, Cidlowski JA. Glucocorticoid receptor signaling in health and disease. Trends in 
pharmacological sciences. 2013;34(9):518-30. doi: 10.1016/j.tips.2013.07.003. PubMed PMID: 
23953592; PMCID: 3951203. 
8. Schaaf MJ, Cidlowski JA. Molecular mechanisms of glucocorticoid action and resistance. J Steroid 
Biochem Mol Biol. 2002;83(1-5):37-48. PubMed PMID: 12650700. 
9. Vilasco M, Communal L, Mourra N, Courtin A, Forgez P, Gompel A. Glucocorticoid receptor and 
breast cancer. Breast Cancer Res Treat. 2011;130(1):1-10. Epub 2011/08/06. doi: 10.1007/s10549-
011-1689-6. PubMed PMID: 21818591. 
10. Lu NZ, Cidlowski JA. Glucocorticoid receptor isoforms generate transcription specificity. Trends in 
cell biology. 2006;16(6):301-7. Epub 2006/05/16. doi: 10.1016/j.tcb.2006.04.005. PubMed PMID: 
16697199. 
11. Ge H, Ni S, Wang X, Xu N, Liu Y, Wang X, Wang L, Song D, Song Y, Bai C. Dexamethasone 
reduces sensitivity to cisplatin by blunting p53-dependent cellular senescence in non-small cell lung 
cancer. PLoS One. 2012;7(12):e51821. doi: 10.1371/journal.pone.0051821. PubMed PMID: 
23272171; PMCID: 3525662. 
12. Greenstein S, Ghias K, Krett NL, Rosen ST. Mechanisms of glucocorticoid-mediated apoptosis in 
hematological malignancies. Clin Cancer Res. 2002;8(6):1681-94. PubMed PMID: 12060604. 
13. Patki M, Gadgeel S, Huang Y, McFall T, Shields AF, Matherly LH, Bepler G, Ratnam M. 
Glucocorticoid receptor status is a principal determinant of variability in the sensitivity of non-small-
cell lung cancer cells to pemetrexed. J Thorac Oncol. 2014;9(4):519-26. Epub 2014/04/17. doi: 
10.1097/JTO.0000000000000111. PubMed PMID: 24736075. 
14. Pang D, Kocherginsky M, Krausz T, Kim SY, Conzen SD. Dexamethasone decreases xenograft 
response to Paclitaxel through inhibition of tumor cell apoptosis. Cancer biology & therapy. 
2006;5(8):933-40. PubMed PMID: 16775428. 
15. Wu W, Chaudhuri S, Brickley DR, Pang D, Karrison T, Conzen SD. Microarray analysis reveals 
glucocorticoid-regulated survival genes that are associated with inhibition of apoptosis in breast 
epithelial cells. Cancer Res. 2004;64(5):1757-64. PubMed PMID: 14996737. 
16. Wu W, Pew T, Zou M, Pang D, Conzen SD. Glucocorticoid receptor-induced MAPK phosphatase-1 
(MPK-1) expression inhibits paclitaxel-associated MAPK activation and contributes to breast cancer 
cell survival. J Biol Chem. 2005;280(6):4117-24. doi: 10.1074/jbc.M411200200. PubMed PMID: 
15590693. 

 18
17. Lu YS, Lien HC, Yeh PY, Kuo SH, Chang WC, Kuo ML, Cheng AL. Glucocorticoid receptor 
expression in advanced non-small cell lung cancer: clinicopathological correlation and in vitro effect 
of glucocorticoid on cell growth and chemosensitivity. Lung Cancer. 2006;53(3):303-10. Epub 
2006/06/30. doi: 10.1016/j.lungcan.2006.05.005. PubMed PMID: 16806572. 
18. Patki M, McFall T, Rosati R, Huang Y, Malysa A, Polin P, Fielder A, Wilson MR, Lonardo F, Back J, 
Li J, Matherly LH, Bepler G, Ratnam M. Chronic p27Kip1 Induction by Dexamethasone Causes 
Senescence Phenotype and Permanent Cell Cycle Blockade in Lung Adenocarcinoma Cells 
Overexpressing Glucocorticoid Receptor. Scientific reports. 2018. Epub October 30, 2018. 
19. Huang WW, Zhu WZ, Mu DL, Ji XQ, Nie XL, Li XY, Wang DX, Ma D. Perioperative Management 
May Improve Long-term Survival in Patients After Lung Cancer Surgery: A Retrospective Cohort 
Study. Anesth Analg. 2018;126(5):1666-74. Epub 2018/03/09. doi: 
10.1213/ANE.0000000000002886. PubMed PMID: 29517574; PMCID: PMC5908254. 
20. Loew D, Schuster O, Graul EH. Dose-dependent pharmacokinetics of dexamethasone. European 
journal of clinical pharmacology. 1986;30(2):225-30. PubMed PMID: 3709651. 
21. Yennurajalingam S, Frisbee-Hume S, Palmer JL, Delgado-Guay MO, Bull J, Phan AT, Tannir NM, 
Litton JK, Reddy A, Hui D, Dalal S, Massie L, Reddy SK, Bruera E. Reduction of cancer-related 
fatigue with dexamethasone: a double-blind, randomized, placebo-controlled trial in patients with 
advanced cancer. J Clin Oncol. 2013;31(25):3076-82. doi: 10.1200/JCO.2012.44.4661. PubMed 
PMID: 23897970. 
22. Cuaron J, Dunphy M, Rimner A. Role of FDG-PET scans in staging, response assessment, and 
follow-up care for non-small cell lung cancer. Frontiers in oncology. 2012;2:208. Epub 2013/01/15. 
doi: 10.3389/fonc.2012.00208. PubMed PMID: 23316478; PMCID: 3539654. 
23. Weber WA, Gatsonis CA, Mozley PD, Hanna LG, Shields AF, Aberle DR, Govindan R, Torigian DA, 
Karp JS, Michael Yu JQ, Subramaniam RM, Halvorsen RA, Siegel BA, Acrin, teams MKR. 
Repeatability of 18F-FDG PET/CT in Advanced Non-Small Cell Lung Cancer: Prospective 
Assessment in 2 Multicenter Trials. Journal of nuclear medicine : official publication, Society of 
Nuclear Medicine. 2015;56(8):1137-43. doi: 10.2967/jnumed.114.147728. PubMed PMID: 
25908829. 
24. Shields AF, Lawhorn-Crews JM, Briston DA, Zalzala S, Gadgeel S, Douglas KA, Mangner TJ, 
Heilbrun LK, Muzik O. Analysis and reproducibility of 3'-Deoxy-3'-[18F]fluorothymidine positron 
emission tomography imaging in patients with non-small cell lung cancer. Clin Cancer Res. 
2008;14(14):4463-8. Epub 2008/07/17. doi: 14/14/4463 [pii] 
10.1158/1078-0432.CCR-07-5243. PubMed PMID: 18628460. 
25. Tehrani OS, Shields AF. PET imaging of proliferation with pyrimidines. Journal of nuclear medicine : 
official publication, Society of Nuclear Medicine. 2013;54(6):903-12. doi: 
10.2967/jnumed.112.112201. PubMed PMID: 23674576. 
26. Zanetti KA, Haznadar M, Welsh JA, Robles AI, Ryan BM, McClary AC, Bowman ED, Goodman JE, 
Bernig T, Chanock SJ, Harris CC. 3'-UTR and functional secretor haplotypes in mannose-binding 
lectin 2 are associated with increased colon cancer risk in African Americans. Cancer Res. 
2012;72(6):1467-77. doi: 10.1158/0008-5472.CAN-11-3073. PubMed PMID: 22282660; PMCID: 
3306468. 
27. Borghaei H, Paz-Ares L, Horn L, Spigel DR, Steins M, Ready NE, Chow LQ, Vokes EE, Felip E, 
Holgado E, Barlesi F, Kohlhaufl M, Arrieta O, Burgio MA, Fayette J, Lena H, Poddubskaya E, 
Gerber DE, Gettinger SN, Rudin CM, Rizvi N, Crino L, Blumenschein GR, Jr., Antonia SJ, Dorange 
C, Harbison CT, Graf Finckenstein F, Brahmer JR. Nivolumab versus Docetaxel in Advanced 
Nonsquamous Non-Small-Cell Lung Cancer. N Engl J Med. 2015;373(17):1627-39. doi: 
10.1056/NEJMoa1507643. PubMed PMID: 26412456. 
28. Rinaldi DA. Overview of phase I trials of multitargeted antifolate (MTA, LY231514). Semin Oncol. 
1999;26(2 Suppl 6):82-8. Epub 1999/12/22. PubMed PMID: 10598560. 
29. Schneider E, Ryan TJ. Gamma-glutamyl hydrolase and drug resistance. Clinica chimica acta; 
international journal of clinical chemistry. 2006;374(1-2):25-32. doi: 10.1016/j.cca.2006.05.044. 
PubMed PMID: 16859665. 

 19
30. Weijtens O, Schoemaker RC, Cohen AF, Romijn FP, Lentjes EG, van Rooij J, van Meurs JC. 
Dexamethasone concentration in vitreous and serum after oral administration. American journal of 
ophthalmology. 1998;125(5):673-9. PubMed PMID: 9625551. 
31. Buck AK, Schirrmeister H, Hetzel M, Von Der Heide M, Halter G, Glatting G, Mattfeldt T, Liewald F, 
Reske SN, Neumaier B. 3-deoxy-3-[(18)F]fluorothymidine-positron emission tomography for 
noninvasive assessment of proliferation in pulmonary nodules. Cancer Res. 2002;62(12):3331-4. 
PubMed PMID: 12067968. 
32. Grierson JR, Schwartz JL, Muzi M, Jordan R, Krohn KA. Metabolism of 3'-deoxy-3'-[F-
18]fluorothymidine in proliferating A549 cells: validations for positron emission tomography. Nucl 
Med Biol. 2004;31(7):829-37. PubMed PMID: 15464384. 
33. Shields AF, Grierson JR, Dohmen BM, Machulla HJ, Stayanoff JC, Lawhorn-Crews JM, Obradovich 
JE, Muzik O, Mangner TJ. Imaging proliferation in vivo with [F-18]FLT and positron emission 
tomography. Nature medicine. 1998;4(11):1334-6. doi: 10.1038/3337. PubMed PMID: 9809561. 
34. Barthel H, Perumal M, Latigo J, He Q, Brady F, Luthra SK, Price PM, Aboagye EO. The uptake of 
3'-deoxy-3'-[18F]fluorothymidine into L5178Y tumours in vivo is dependent on thymidine kinase 1 
protein levels. European journal of nuclear medicine and molecular imaging. 2005;32(3):257-63. 
doi: 10.1007/s00259-004-1611-0. PubMed PMID: 15791434. 
35. Vesselle H, Grierson J, Muzi M, Pugsley JM, Schmidt RA, Rabinowitz P, Peterson LM, Vallieres E, 
Wood DE. In Vivo Validation of 3'deoxy-3'-[(18)F]fluorothymidine ([(18)F]FLT) as a Proliferation 
Imaging Tracer in Humans: Correlation of [(18)F]FLT Uptake by Positron Emission Tomography 
with Ki-67 Immunohistochemistry and Flow Cytometry in Human Lung Tumors. Clin Cancer Res. 
2002;8(11):3315-23. PubMed PMID: 12429617. 
36. Flexner C, van der Horst C, Jacobson MA, Powderly W, Duncanson F, Ganes D, Barditch-Crovo 
PA, Petty BG, Baron PA, Armstrong D, et al. Relationship between plasma concentrations of 3'-
deoxy-3'-fluorothymidine (alovudine) and antiretroviral activity in two concentration-controlled trials. 
The Journal of infectious diseases. 1994;170(6):1394-403. PubMed PMID: 7995977. 
37. Vanderhoek M, Perlman SB, Jeraj R. Impact of the definition of peak standardized uptake value on 
quantification of treatment response. J Nucl Med. 2012;53(1):4-11. Epub 2012/01/04. doi: 
10.2967/jnumed.111.093443. PubMed PMID: 22213818; PMCID: PMC3308343. 
38. Harrell F. Regression Modeling Strategies:  With Applications to Linear Models, Logistic 
Regression, and Survival Analysis. . New York: Springer Science and Business Media, Inc.; 2001. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
20
APPENDIX A:  STUDY SCHEMA