Conditions: Adult Hepatocellular Carcinoma Localized Resectable Adult Liver Carcinoma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 64
Healthy volunteers: no

Brief summary:
This clinical trial studies positron emission tomography (PET)/computed tomography (CT) in diagnosing patients with liver cancer undergoing surgical resection. Diagnostic procedures, such as fluorine-18 fluoromethylcholine PET/CT, may help find and diagnose liver cancer.

Detailed description:
PRIMARY OBJECTIVES:

I. Determine the most optimal fluorine-18 (18F) fluoromethylcholine (FCH) PET/CT parameters for detecting primary hepatocellular carcinoma (HCC) by conducting a clinical radiologic-pathologic correlation study to estimate and compare the receiver operating characteristics of kinetic and static PET measures of tumor FCH metabolism in patients that test positive during screening or conventional imaging.

II. Identify cancer signaling pathways associated with choline metabolism in HCC by profiling the global gene expression patterns in fresh-frozen liver tissue samples that are correlated with the features derived from FCH PET/CT images.

III. Characterize the association between features derived from FCH PET/CT images of the liver and clinical liver disease severity and comparatively evaluate the ability of corresponding gene expression signatures to predictively model HCC disease outcome.

OUTLINE:

Patients undergo 18F-fluoromethylcholine PET/CT within 14 days of surgical resection.

After completion of study treatment, patients are followed up periodically.

Arms:
arm 1: Patients undergo 18F-fluoromethylcholine positron emission tomography (PET)/ computed tomography (CT) scan within 14 days of surgical resection of liver tumor.

Interventions: intervention 1: Computed Tomography intervention 2: 18F-fluoromethylcholine intervention 3: Positron Emission Tomography
Intervention descriptions: intervention 1: Undergo FCH PET/CT intervention 2: Undergo FCH PET/CT intervention 3: Undergo FCH PET/CT

Protocol document:
Prot_000.pdf: 
Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
 
 
 
Study Protocol 
 
 
 
Study Name:  Genomic and Imaging Study for Patients Undergoing Surgery for 
Liver Cancer 
 
Principal Investigator:  Sandi Alexander Kwee, MD 
 
Primary study site: The Queen’s Medical Center, Honolulu, Hawaii 
 
Primary site identifier: RA-2011-025 
NCI CTRP identifier: NCI-2012-02095 
Clinicaltrials.gov identifier: NCT01395030 
 
IRB Approved Version Date: August 18, 2014 
 
Next IRB approval expiration date: September 30, 2018 
 
 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
Study Name:  Genomic and Imaging Study for Patients Undergoing Surgery for Liver Cancer 
Principal Investigators:  Sandi Kwee, MD 
 
Detailed Study Protocol 
 
I.1. Study Protocol Schedule 
 
Enrollment: 
-Signed consent form and completed eligibility checklist (Oncology Research Department 
(ORD) Nurses to complete Patient Selection Criteria and Enrollment).   
-Relevant clinical documentation is reviewed by the PI (Dr. Kwee) prior to authorization to 
schedule PET/CT appointment. 
-Serum pregnancy test is performed (if appropriate). 
-PET/CT appointment is scheduled. 
 
Imaging Appointment (1.5h): 
-PET/CT using Liver F-choline Scan Protocol within 14 days of surgery. 
 
Day of Surgery: 
-UHCC Pathology Shared Resource personnel  are notified and available for specimen procurement. 
-Specimen obtained under UHCC Specimen Procurement Standard Operating Procedure (see Ap-
pendix following this Protocol). 
 
Follow-up 
- Blood tests which include a comprehensive metabolic panel (includes liver function and chemistry 
panel), protime and complete blood count will be drawn at the subject’s 1-4 week follow-up visit with 
their surgeon.   These tests will be performed by a certified diagnostic laboratory such as DLS.   If 
subject agrees, an optional research blood sample will also be collected and sent to UHCC for anal-
ysis.  
-Subjects are also enrolled into the Hawaii Tumor Registry. Therefore, the ORD staff will not be 
involved in extended follow-up data collection, given that this falls within the scope the State-
mandated tumor registry activities. 
 
I.2. Criteria for Patient Selection 
Inclusion Criteria: Inclusion Criteria:  1) > 18 years of age.  No upper limit of age. 2) liver tumor diagnosed 
histologically as HCC or suspected of being HCC in association with serum alpha-fetoprotein level > 200 or 
tumor mass with characteristics of malignancy on diagnostic imaging, 3) under the care of a surgical attending, 
4) deemed a surgical candidate and has agreed to surgery to remove a  portion of the liver containing tumor, 
and 5) Child-Pugh A/B. 
Exclusion Criteria:  1)  Weight > 350 lbs (PET/CT limit); 2)  pregnant or lactating female, a serum pregnancy 
test will be performed within 2 weeks or less before the date of the FCH PET/CT scan in all women capable of 
becoming pregnant; 3) serious underlying medical condition that would impair patient’s ability to tolerate the 
imaging procedure; 4) concurrent treatment with chemotherapy, molecule-selective,  biological, or radiothera-
peutic agent. 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
I.4. Method of Enrollment and Follow-up 
Written informed consent will be obtained by the PI or other physician listed on FDA Form 1572.   The Re-
search Nurse (Karen Ng or other ORD nurse) or Associate (Miles Sato or other ORD Associate) will assist the 
PI with recruitment, enrollment, scheduling, and follow-up.     
 
If the subject experiences a serious adverse event, follow-up of the adverse event to its conclusion will ulti-
mately be the responsibility of the PI and the IND sponsor-investigator (who serves as co-investigator on this 
study).  The patient’s treating physician will be allowed to assist with clinical follow-up.   
 
I.4.1. Authenticating Disease Progression 
Clinical information (test results, etc.) will be reviewed for the purpose of confirming inclusion/exclusion criteria.  
  Evidence of disease progression will be collected and made available for descriptive purposes and retrospec-
tive analyses.  Data collection to support authentication of disease progression will include documentation of 
patient demographics, age, performance status, clinical stage, details and dates of the primary therapy, and 
post-treatment clinical status.  The presence of potential disease sites will be documented based on reports of 
any available imaging studies including but not limited to CT, MRI, ultrasound, and bone scan.  This data will 
be assembled on study specific forms by the personnel for this study.  The PET image data and genomics data 
are high-dimensional datasets.  This type of data will not be available in study forms but will remain in their 
source format.  The survival data will also not be collected by study personnel or entered into the study specific 
forms, since they will be obtained directly from the Hawaii Tumor Registry through query reports.   
 
 
I.5. Method for Determining Doses, Maximum dosage, and Duration of Patient Drug Exposure  
Patient dose has been determined by the least radiation dose from the radiopharmaceutical that will provide 
enough counts in the tomograph detectors to obtain quantifiable images with adequate counting statistics.  The 
exposure of the patient to the radiopharmaceutical will only be until the radioactive label decays.  The half life 
of fluorine-18 is 109.8 minutes.  Maximum duration of radiation exposure is therefore limited by this half-life.  
The number of doses administered is determined by the number of PET/CT scans required by the study proto-
col.  The total effective dose will not exceed reasonably safe limits set by the FDA as described in the investi-
gator’s brochure for 18F-choline.  Each dose of 18F-choline is administered intravenously as a single unit 
dose. A radioactivity dose of 0.09 milliCuries per kilogram of body weight will be prescribed and obtained from 
the cyclotron laboratory.  A dose calibrator in the PET imaging suite will be used to confirm the actual dose to 
be administered.  Only a dose falling within a 10% range of the calculated prescribed dose will be adminis-
tered.   
I.6. Observations and Measurements to Fulfill the Objectives of the Study 
Source documents (clinical, radiographic, and pathology reports), obtained from the medical record (office or 
hospital) following subject written informed consent, will be abstracted to generate a list of known sites of ac-
tive disease.  A table of these sites for each subject will be entered into a password-protected database.   
 
I.7 Investigational Observations and Measurements to Fulfill the Objectives of the Study 
The 18F- Choline injection is infused into the subject intravenously over 1 minute.  The PET scanning is started 
approximately 10 minutes after the start of infusion.  PET imaging data, from the neck to the proximal femur is 
then collected.  PET data is analyzed by: a) visual assessment, and b) semi-quantitative region of interest 
(ROI) analysis.  Standardized uptake values (SUV) will be recorded from each ROI.  Implicit in the definition of 
SUV is the requirement that the tomograph be properly calibrated so that activity in tissue can be determined in 
uCi/ml.  Structural imaging (CT, MRI) when available will be used for anatomical correlation. If a PET/CT scan 
is performed, the CT performed for attenuation correction will provide some anatomical correlation data.  The 
PET/CT imaging protocol is described in section I.10.  
 
Patients will routinely schedule follow-up visits with their surgeons at 1-4 weeks post-op.  After this visit, the 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
study will perform blood tests which include a complete blood count, protime and comprehensive metabolic 
panel (CMP).  These tests will be provided through a commercial testing laboratory (eg. Diagnostic Laboratory 
Services, Inc.).  The results of these clinical laboratory test results will be compared to the pre-operative PET 
imaging findings to investigate whether PET may be predictive of post-surgery liver function.  This is consistent 
with Specific Aim 3 of the research study.  
If the research subject agrees, additional research blood samples will be obtained immediately before and 1-4 
week following liver resection surgery. These samples will be sent to UHCC for analysis. If the patient is having 
other blood tests, these samples can be collected with the other tests.  Using sterile technique, an intravenous 
needle will be inserted by a trained IV technician into an arm vein. A total of approximately 4 tsp of blood will 
be withdrawn into two vacutainer tubes.  The sample centrifuged to isolate plasma fraction, buffy coat, and pel-
let.  These samples will be frozen and analyzed in batches later to provide data on germline DNA, RNA, mi-
croRNA, and circulating RNA/DNA.  The same procedure will be applied to the pre-surgery and post-surgery 
sample collections. If the results of a recent (within 3 months) fasting lipid profile (ie. cholesterol blood test) are 
not available, a fasting lipid profile will be obtained by Diagnostic Laboratory Services at the time other base-
line laboratory samples are being obtained by the study.  This information will be compared with the PET imag-
ing and tissue expression data, providing reference values for the genomic analyses (Specific Aim 2).  These 
blood samples will be used only to pursue the goals of this study, and will not be stored and made available to 
other research studies. 
 
I.8. Clinical Procedures or other Measures to Monitor the Effects of the Drug in Human Subjects  
Vital signs (e.g., temperature, heart rate, blood pressure, respiratory rate) will be measured on each subject 
prior to radiotracer administration.  Vital signs will be repeated at the conclusion of PET imaging.  During and 
after the PET/CT scanning procedure, subjects will be asked if they are experiencing any unusual symptoms.   
 
I.9. Policy regarding human subjects and informed consent 
Research involving human subjects is covered by federal law and institutional policies.  All research conducted 
at our institution requires review and pre-approval by a Scientific Review Committee followed by approval from 
an Institutional Review Board.  Subjects will be given a Queen’s Medical Center IRB-approved consent.   
 
I.10. PET/CT Protocol 
 
Instrument: Gemini TF-64 PET/CT (Philips Medical Systems N.A., Bothell, WA) 
Scan Protocol: Low-Dose CT, Liver PET Protocol 
Isotope Dose: 18F-Fluoromethylcholine, 0.09 mCi/kg patient body weight on day of scan. 
 
1. A copy of the signed consent form will be faxed to the Research Regulatory Office. 
2.  Height, sex, and age of the patient are recorded.  Body weight, blood pressure, pulse, temperature and res-
piratory rate are obtained.  The obtained weight is used to determine 18F-choline dose. 
3.  Using sterile technique, an intravenous catheter is inserted by a trained IV technician into an arm vein.  The 
catheters are flushed with sterile saline.  The patient is placed in the supine position on the scanning table. 
4.  A vial of 18F-choline containing a dose of 0.09 mCi/kg of body weight will be obtained from the cyclotron 
laboratory.   A dose calibrator in the PET imaging suite will be used to confirm the actual administration 
dose.  Only a dose falling within a 10% range of the calculated prescribed dose will be administered.   
5. A topographic scan will be performed to identify anatomical boundaries and the axial imaging field of view. 
The field of view is to encompass the liver, with 1cm margin from the upper limit of the field.  
6.  A CT transmission scan in the supine position is acquired over the upper abdomen.  The 64-channel helical 
CT scanning parameters were: 120 kV, 30-50 mA/slice, rotation time 0.75 sec, slice thickness/interval 
5.0mm.  No intravenous contrast will be used with CT.   
7.  The 18F-choline is injected by bolus followed by a 10 cc saline flush.  Image acquisition is begun immedi-


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
ately with the flush in a dynamic mode using the following timing schema:   
Frame # 
Duration (seconds) 
1-20 
10 
21-23 
40 
24-27 
120 
28-30 
240 
31 
360 
However, if it is determined in the initial 5 subjects that the dynamic imaging data fits well into a 1-tissue kinetic 
model of FCH uptake where activity levels eventually plateau or become linear, then the dynamic scan can 
be shortened (to 12-15 minutes, for example) and the dynamic frames curtailed accordingly. 
 
8.  A short 3-minute static scan of the liver will be performed subsequent to the dynamic scan, and rapidly re-
constucted to provide the investigators an immediate image for review of quality control and biodistribution.   
The operating characteristics of this PET device are described elsewhere (Surti S, et al. J Nucl Med. 
2007;48(3):471-480. ) 
9.  After the scan, patient blood pressure, pulse, respiratory rate, and temperature are measured a recorded.  
Subjects are released pending investigator review of the vital signs and flow sheet. 
10. Image reconstruction will employ a list-mode version of a maximum likelihood expectation maximization 
algorithm with a time-of-flight kernel applied in both the forward- and back-projection operations.  CT data 
is used for attenuation correction.  Reconstructed images in 3 orthogonal planes will be reviewed on a ded-
icated PET/CT viewing station and will be archived on removable media in DICOM format.  
 
I.11. Facilities Data 
The facilities used to carry out the activities described in this document are located at the Queen’s Medical 
Center, 1301 Punchbowl St., Honolulu, HI 96818.  These facilities include the Hamamatsu/Queen’s PET Imag-
ing Center which houses the tomograph, and the Liholiho Cyclotron Building which houses the accelerator.  
The accelerator used to produce radioisotopes is an 11 MeV RDS-111 (CTI, Knoxville, TN) with the required 
beam line and targetry systems.  The radiochemistry laboratories house production systems and robotics, a 
pneumatic system for transfer of radiopharmaceutical to the imaging area, and adequate equipment and labor-
atory space for radiopharmaceutical production and quality control.  The hot lab contains 2 hot cells (Von 
Gahlen, Netherlands), organic chemistry space for compound production and development, and a small radio-
pharmacy in the imaging suite.  There is 110 square feet of radioanalytical instrumentation and desk space for 
radiochemistry work.   
Handling of all radioisotopes is conducted under the supervision of the hospital Radiation Safety Office 
(RSO).  RSO personnel will regularly monitor the radiopharmaceutical laboratories for radioisotope contamina-
tion.  All personnel using radioisotopes will wear a film badge and those handling isotopes will wear finger ring 
badges to monitor integrated radiation absorbed dose.  Disposal of radioactive waste is only in specially desig-
nated and properly shielded receptacles.  The laboratory is monitored for radioactivity by external monitoring 
and wipe tests.  The short half-life of fluorine-18 insures that no long-term radiation safety problem is engen-
dered.  All equipment is tested regularly as to its operation.  Specifically, the dose calibrator is tested for con-
stancy each day it is used, its linearity quarterly, and its accuracy annually.  Logbooks record these measure-
ments.  Radiation survey instruments, including safety monitors (hand and foot) and personal dosimeters, are 
calibrated at least annually and following any repairs.  All calibration procedures and schedules for radiation 
monitoring devices are reviewed and approved by the RSO.  The PET imaging facilities are located in the first 
floor of Queen’s Medical Center, adjacent to the Nuclear Medicine clinic.  This area houses the PET/CT de-
vice.  There are existing waiting rooms and patient examination facilities in the clinic and physician and nursing 
personnel are available on premises.  The rooms of the PET suite are the 1) two tomograph rooms, one con-
taining a Hamamatsu SHR-22000 PET system, and another containing a Philips Gemini TF PET/CT scanner 
with 64-slice CT, 2) a control room with a small radiopharmacy laboratory, 3) the administration and patient 
holding room, and the 4) a data analysis and display room located in the Nuclear Medicine clinic.   


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
I.12. Institutional Review Board Data 
This study with [18F] fluorocholine requires review by the Queen’s Medical Center Institutional Review Board.  
Our institutional review process is composed of two parts.  A Scientific Review Committee (SRC) preliminarily 
reviews all new research proposals with the exception of retrospective studies.  If passed by the SRC, an 
Institutional Review Board (IRB) will then conduct the initial and continuing review and approval of any project 
involving human subject research.  The address of the Queen’s Medical Center IRB is: 
 
Research and Institutional Review Committee 
 
 
Institutional Review Board 
The Queen’s Medical Center 
1301 Punchbowl Street, University Tower Room 505 
Honolulu, HI 96813 
 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
  
Appendix: Standard Operating Procedures for Collection of Tumor and Liver Tissue Specimens 
 
 
1.0  
Scope and Applicability  
This standard operating procedure (SOP) describes the methods for tissue sample collection, 
preparation, storage, and reporting. 
2.0  
Definition  
2.1  
Research Subject Information and Consent Form: This is the signed document allow-
ing consent (i.e., Chain of Custody records), by the patient and surgeon.  This document must be 
available before or during the surgical procedure before the patient is included into his study.  A 
Photo copy of the document must be available at the Queen’s Medical Center, Hawaii Medical 
Center Pathology laboratory and the Cancer Research Center oh Hawai'I (CRCH). 
4.0 
Responsibilities  
3.0  
Cautions  
3.1  
Tissue samples must be handled expediently and properly, as the tissue quality will be ad-
versely affected by prolonged transport time or changes in temperature.   
3.2  
To minimize the potential for cross-contamination of samples, sterile technique and use 
of sterile equipment or sterilized instruments will be available through Cancer Research Center 
of Hawaii personnel.    
1. Sterile gloves, Derm Assist, size 7.5, R.Weinstein #132750,  50 pairs per box 
2. Sterile gloves, Triflex, size 7.5, Cardinal #2D7254, 40 pairs/box 
3. Sterile gauze, ProAdvantage, 4 x 4, R.Weinstein #P157025, 25 x2 /package 
4. Sterilized forceps, VWR, 6” round tip dissecting, 82027-378, pack of 12 
5. Sterilized knife handle, Cardinal #4781, each. 
6. Sterilized Autopsy Knife Blade, Cardinal, #4783, each. 
2.2  
Surplus Tissue:  Tissue normally discarded by the pathology lab.  This material will be des-
ignated by pathology personnel and retained by Cancer Research Center of Hawaii personnel. 
4.1  
Surgical staff (Surgical Associates office 523-0166) is responsible for identifying 
potentially eligible cases and notifying CRCH lab (440-5238) of patient’s surgical date and 
time. 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
 
v. 01/18/10  
4.2  
CRCH is responsible for notifying the pathology laboratory (547-6536) of the surgery 
and preparing instrument sterilization and supplies.  CRCH is also responsible for coordinating 
and monitoring tissue sample collection, transportation and providing technical assistance as 
needed. 
4.3  
Pathology Lab is responsible for receiving and analyzing the tissue samples, and ali-
quoting a portion of the desired entity to CRCH. 
5.0 
Apparatus and Materials  
5.1  
Gloves, sterile **  
5.6  
Cooler, Igloo transport, with three (3) sterile specimen containers and ice*  
5.5  
Knife blade, autopsy, disposable, sterilized**  
5.4  
Knife handle for Autopsy knife blade, sterilized**  
5.3  
Forceps, dissecting, sterilized**  
5.2  
Gauze, sterile**  
5.7  
Specimen ID Labels, preprinted*  
5.8  
Specimen Accession sheet*  
5.9  
Zip-lock Bags*  
5.10  
Surgical blades, sterile*  
5.11  
Cryogenic storage Boxes*  
5.12  
Allprotect, Qiagen, #76405 or RNA Later*  
5.13  
Formalin*  
** Item will be used by hospital 
. * Item will be used by CRCH.  
6.0  
Procedure  
6.1  
Sample Collection Criteria:  
6.1.1.  Any fresh surgical tissue from human liver samples that have been identified by 
surgeon.  


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
 
v. 01/18/10  
6.1.2.  Tissue selection based on (1) representative histology from primary site, (2) corre-
spondence to a specific area on PET/CT if identified by radiologist, (3) minimal necrosis, (4) 
sufficient residual tissue to constitute Surplus tissue requirement.  Biopsy samples should not 
be selected unless the pathology lab has approved its availability.   
6.1.3.  At minimum, two 0.5 cm cubes, one of tumor and one of normal tissue are re-
quested.  
6.2  
Sample Preparation:   
6.2.1  Surgical team will deliver fresh, specimen to Pathology lab.    
6.2.2  Gloves must be worn when handling or cutting liver sections.  
6.2.3  Use a new, sterilized, disposable autopsy blade and forcep to minimize the poten-
tial for RNA contamination of samples. Sections for CRCH should be taken using “Sterile 
Technique.”   
6.2.4  At minimum, two core cubes are requested.  For large tumors (> 5 cm greatest di-
am.), multiple tumor and normal specimens will be collected and numbered A1, A2 etc:  
o  
Section A for tumor – Minimum 0.5 cm. cube.  Label as “Sample _A”  
o  
Section B for normal, adjacent – 0.5 cm cube.  Label as “Sample_B”  
o  
Sections C or more  –  0.5 cm.cube. Label as “Samples C,” etc. May be substi-
tuted as necessary. 
o  
Section  for non-liver – No sections, unless directed by the P.I., surgeon, or 
pathologist. 
6.2.5  All sections should be labeled and provided a discrete accession sequence under the 
CRCH numbering scheme.  Record each sample description on the Specimen Accession 
Form, as approved by Pathology.  
6.3  
Documentation/Reporting:  
6.3.1  CRCH will retrieve the subject’s tissue sample from HMC and process the tissue 
sample according to the SOP.    
6.3.2  The specimen IDs are pre-printed and labels will be attached to the Specimen Acces-
sion Form.  ID labels are meant to be placed on the sterile specimen container at the time of 
collection.  
3  


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
v. 01/18/10  
6.3.3  The CRCH number must be recorded on the signed Research Subject Information 
and Consent Form.  Please review the form for the appropriate signatures.  Incomplete 
forms will be rejected, and no tissue collection will be done. 
6.3.4  Record the information requested on the Specimen Accession Form.  Please write 
or Addressograph: 
6.3.4.1 Patient name,  
6.3.4.2 Physician,  
6.3.4.3 Surgical procedure,  
6.3.4.4 Surgery date,  
6.3.4.5 Surgery time,  
6.3.4.6 Patient Consent Form, yes or no, 
6.3.4.7 Time delivered to pathology lab 
6.3.4.8 Date and time of pick-up 
6.3.4.9 Initials of person doing pick-up 
 
If the pre- or post-operation diagnosis is available, please indicate them under “Rel-
evant Information.” Please write legibly and provide remarks for each sample if needed 
with any issues or concerns.   
6.3.5   One sample per accession(i.e., Do Not mark more than one site per entry.)  The 
Specimen Accession Form must be filled. 
6.3.6 
A finalized copy of the surgical report is requested.  This may be either faxed or mailed to:  
 
Brenda Hernandez 
 
1236 Lauhala street, Suite 407 
 
Honolulu, Hawaii 96813 
 
Fax: (808) 586-2982 
6.4  
Transporting Fresh tissue to CRCH:  
6.4.1  Prepare ice chips or cool packs. Depending on the number of samples to be transport-
ed, the cool chest is hard sided and contains enough ice to cool tissues, but not freeze.  Study 
staff should put the cool packs in a refrigerator or standard freezer.  (Note: Do not put the 
cool packs in the -80 C freezer).  
6.4.2  Put sterile specimen containers (6) in transport cool chest.  Also, one zip-lock bag, 
gallon sized. 
4  


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
   
v. 06/10/09  
 
6.5 
Handling and Storage. 
6.5.1 
Liver samples will be cut using a sterile technique into 4 equal parts: 
6.5.1.1 RNA Later, stored in -20c 
6.5.1.2 Allprotect, stored in -80c 
6.5.1.3 Cryovial storage, stored in liquid nitrogen 
6.5.1.4 Formalin fixation, followed within 24 hours by tissue processing.  All 
excess tissue given will be processed, rather than discarded. 
6.5.2  Sections will be accessioned onto a CRCH database and the exact locations of 
the different samples will be plotted.   
7 
Procedure 
7.1 
Surgical Associates (523-0166) will notify CRCH Lab (440-5238) of surgical 
scheduling of a prospective participant.  This must include: 
 
7.1.1 
Patient identifier. 
7.1.2 
Surgical date. 
7.1.3 
Surgical time. 
7.2 
CRCH lab will notify pathology lab of the scheduling.   
7.3 
CRCH will arrange transportation and supplies for the surgical collection. 
7.4 
On the day of the surgery, surgery staff (547-6260) will notify CRCH within 30 
minutes of expected dissection. 
7.5 
The pathology receives and dissects specimen.  Instruments and tools will be 
handled by CRCH lab. 
7.6 
CRCH transports the tissue specimens back to CRCH 
7.7 
CRCH further dissects the specimen into the following components 
7.7.1 
DNA, RNA, and protein  
7.7.1.1 
Allprotect or RNA Later 
7.7.2 
Cryopreservation, Snap freezing into liquid nitrogen 
7.7.3 
Fresh frozen paraffin embedded (FFPE), permanent storage 
 
 


Program Director/Principal Investigator (Last, First, Middle): Kwee, Sandi Alexander 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
v. 06/10/09  
9.0 Quality Control and Quality Assurance  
9.1 
To ensure tissue sample/data quality, CRCH will monitor the tissue sample collection 
process.  If sample quality or any processing issues occur, CRCH will modify the 
SOP and notify all offices and/or labs involved to resolve any problems or issues. 
10.0 
Reference: 
N/A 
8.0 
Records  
8.1 
CRCH will secure and retain all pertinent records as required by HIPAA. 

SAP_001.pdf: 
Statistical Analysis Plan for clinical research study RA-2011-025 
“Genomic and Imaging Study for Patients Undergoing Surgery for 
Liver Cancer”  
Primary Site Study identifier: RA-2011-025  
NCI CTRP identifier: NCI-2012-02095  
ClinicalTrials.gov identifier: NCT01395030  
Excerpted without modification from page 87 of the grant 
application of NIH/NCI grant award R01CA161209, approved July 1, 
2011 (NIH Project Start Date)  
 
 


 
Statistical Approach and ROC Analysis: Excel (Microsoft) and SAS ver9+ 
(SAS Institute) will be used for statistical analysis. Kinetic analysis will be applied 
to all PET studies to obtain the relevant parameters (e.g., K1 and Vd) of the 
model selected. The following static and kinetic PET parameters will be 
considered: SUVmax, SUVmax normalized to lean body mass, visual score (1-5 
intensity), TBR, and tentatively K1 and Vd. Logistic models will be used to 
regress tumor presence, based on histopathologic or follow-up diagnosis, for 
each tu- mor sample on each PET parameter, expressed on a continuous or 
ordinal scale. Similarly, logistic regression will assess the association between 
PET parameters and tumor features such as histologic grade and vascular 
invasion. Data may be grouped and considered by underlying liver disease (eg. 
HBV, HCV, NASH, etc.).  
The diagnostic performance of kinetic and static (i.e., SUV) PET parameters as 
predictors of histopathologic diagnosis will be assessed by using ROC analysis 
as in previous studies (42, 45). The primary unit of analysis will be individual 
tumor specimens, although subsequent analyses may be performed at the 
patient level. For each parameter, the ROC curve will plot sensitivity versus 1 
minus specificity for a range of parameter thresh- old values. Areas under the 
ROC curve (AUC) will computed along with 95% confidence intervals as an indi- 
cator of overall diagnostic performance. The relative diagnostic performance of 
the PET parameters will be assessed by comparing their AUCs using non-
parametric methods for comparing two or more ROC curves es- timated from the 
same set of patients (52). A global test of all curves will be made and then if 
warranted, pair- wise comparisons will be made, controlling for multiple 
comparisons. The potential confounding effect of vari- ous patient or tumor 
characteristics on the ROC curve will be explored by regressing the curve on the 
confounders (53, 54). These adjustment variables will be limited in number given 
the sample size. Tests will be 2-sided, and p-values < 0.05 will be considered 
significant. Individual patients may have more than one tis- sue sample in this 
analysis. However, controlling for the correlation structure, such as by 
overdispersion con- trol, will not affect the ROC analysis. Therefore, sensitivity 
analysis, as a search for possible influential pa- tients, will be made by jackknife 
analysis. Classification thresholds will be defined for each PET parameter, 
corresponding to the point on the ROC curve that is maximally distant from the 
“chance” line in ROC-space.