FLT-PET Imaging in Invasive Breast Cancer Treatment Monitoring

1. ACRIN 6688PHASE II STUDY OF 3'-DEOXY-3'-18F FLUOROTHYMIDINE (FLT) IN INVASIVE BREAST CANCERPrincipal Investigator: Lale Kostakoglu, MD 9/30/10

2. Recent advances in cancer treatment occurred in the development of disease specific molecular agents, many of which induce cell cycle arrest (cytostatic effect) inhibiting cell proliferation and tumor growth Evaluating alterations in DNA metabolism may reflect therapy response better than changes in glucose utilization FDG reflects tm proliferation only in part and associated with FPs due to tracer retention in inflammatory processes [F-18] FLT Background

3. FLT is a structural analog of thymidine Although FLT is not incorporated into DNA, it is trapped in the cell due to phosphorylation by TK FLT PET enables non-invasive imaging and quantification of the tm proliferative fraction in proportion to DNA synthesis rate FLT PET can be used as an imaging probe to assess in vivo cellular proliferation in malignant tumors, especially with targeted drugs [F-18] FLT Background Buck AK, Methods 2009: 48:205

4. Because of lower overall tm uptake and high bckg activity in the liver and bone marrow, FLT is not expected to have the same sensitivity as FDG for tumor detection across all organs FLT-PET is considered a potentially powerful tool to provide additional diagnostic specificity for proliferating tissues Provide important biological info that could have implications in treatment selection or monitoring [F-18] FLT Background Salskov A , Semin Nucl Med 2007;37:429

5. Preliminary Studies proliferation dependent accumulation of FLT Buck AK, Methods 2009: 48:205 The high cc’s observed between FLT uptake and Ki67 measurements implicate that cellular uptake of FLT is predominantly caused by proliferative activity

6. Non-invasive detection and grading of malignant lymphoma using FLT PET as surrogate marker of tumor proliferation Ki-67 labeling index: >90% aggressive lymphoma Ki-67 labeling index: < 5% Low grade lymphoma Buck AK, Methods 2009: 48:205

7. Kenny, EJNM 34:1339, 2007 FLT in BREAST CANCER • Aim: a. determine FLT-PET response at 1 wk in pts treated • with chemo b.determine the reproducibility of serial scans • 17 discrete lesions in 13 stage II–IV breast ca pts • Imaging prior to and at 1 wk after treatment with chemo • Clinical response assessed 60 dys after commencing chemo • 6 pts had a significant clinical response at day 60; these pts also had a • significant reduction in FLT uptake at 1 wk • Decrease in SUV at 1 wk discriminated btw clinical response and SD • (p=0.02) • FLT response generally preceded tm size changes SUVmax in CR/PR SUVmax in SD

8. Pre Therapy Post Therapy 7 dys post- therapy RESPONSE in a patient with grade II lobular ca NO RESPONSE in a patient with grade II IDC 7 dys post- therapy Kenny, EJNMMI 34:1339, 2007

9. Reproducibility of [18F]FLT Parameters Kenny, EJNMMI 34:1339, 2007 Shields, AF, Clin Cancer Res. 2008;14:4463 The box plot shows the mean percent error (horizontal line within the box), the 25th and 75th percentiles (bottom and top of box, respectively), and the range (bottom and top horizontal bars on vertical whiskers).

10. VIRGINIA COMMONWEALTH UNIVERSITY AMERICAN COLLEGE OF RADIOLOGY IMAGING NETWORK ACRIN 6688 (amendment 6) PHASE II STUDY OF 3'-DEOXY-3'-18F FLUOROTHYMIDINE (FLT) IN INVASIVE BREAST CANCER

11. Protocol Investigators VCU Study ChairVCU Study Co-ChairVCU Study Co-Chair Paul R Jolles, MD Harry D Bear, MD, PhD Michael O Idowu, MD Dept Radiology Dept of Surgery Dept of Pathology Richmond, VA Richmond, VA Richmond, VA prjolles@vcu.eduhdbear@vcu.edumidowu@mcvh-vcu.edu ACRIN Study Co-ChairACRIN Study Co-Chair David Mankoff, MD, PhD Lale Kostakoglu, MD, MPH Professor of Radiology Professor of Radiology Seattle Cancer Care Alliance Mount Sinai School of Medicine Seattle, WA New York, NY 10029 dam@u.washington.edulale.kostakoglu@mssm.edu VCU Study StatisticianACRIN Study Statistician Donna K McClish, PhD Fenghai Duan, PhD Department of Biostatistics Ctr for Statistical Sciences Richmond, VA 23298 Brown University mcclish@mail2.vcu.edufduan@stat.brown.edu

12. Primary Objective: To correlate the percentage change in SUVs between baseline (FLT-1) and early-therapy (FLT-2) with pCR (as a dichotoumous variable) to neoadjuvant chemotherapy of the primary tumor in patients with locally advanced breast cancer (LABC) Changed to early therapy from mid-therapy Study Objective

13. evaluate correlation or relationship between, FLT1 and FLT3 uptake parameters and proliferation markers FLT1, FLT2 and FLT3 uptake parameters and PCR of the primary tm and residual cancer burden (RCB) FLT1, FLT2 and FLT3 uptake parameters and non-response of the primary tm (SD or prog) FLT1, FLT2 and FLT3 uptake parameters and PCR to neoadjuvant in pts with regional disease in the LNs compare changes of, FLT2 and FLT3 uptake parameters to changes in tm sizes from other serial imaging modalities (mammogram, MRI, and US, as available) FLT2 and FLT3 uptake parameters to metabolic changes from FDG PET, as available monitor for potential safety issues and define any physiologic effects associated with FLT administration Secondary Objectives

14. Obtain post-treatment proliferative Indices Obtain pre-treatment proliferative Indices Baseline Imaging Early therapy Imaging Establish Eligibility Post-therapy Imaging Surgical Resection Chemotherapy cycle 1 • Baseline organ function • Pathologically confirmed disease • Determine primary systemic Rx Ki-67 and mitotic index on bx sample or re-biopsy (if available) 18FLT PET/CT (FLT-1) 18FLT PET/CT (FLT-2) 18FLT PET/CT (FLT-3) • Pathologic response, • Ki-67 and mitotic index, surgical specimens [F-18] FLT Study Outline Chemotherapy last cycle

15. Three imaging sessions pre-treatment (FLT-1), after one cycle (FLT-2), at completion (FLT-3) FLT-1 (baseline PET) must be completed within 4 wks prior to chemo initiation FLT-2 (early PET) must be performed 5-10 dys after initiation of the first chemo cycle FLT-3 (post therapy PET) will be performed after the completion of chemo and within 3 wks prior to surgery Timing of FLT PET Studies

16. There is no specific neoadjuvant chemo regimen required for this protocol Several neoadjuvant therapy protocols are currently used at participating institutions and subjects for the study may be recruited from prospective neoadjuvant chemo trials, which may also include targeted agents, such as trastuzumab However, patients on neoadjuvant protocols using hormonal therapy alone are not eligible Neoadjuvant Therapy

17. Pathologically confirmed breast cancer, determined to be a candidate for neoadjuvant therapy and for surgical resection of residual primary tm after neoadjuvant therapy Tumor size >2cm, measured on imaging or estimated by PE No obvious contraindications for primary chemotherapy Residual tumor planned to be removed surgically following completion of neoadjuvant therapy Age >18 ECOG Performance Status ≤ 2 (Karnofsky ≥ 60%) Normal organ and marrow function at 1st visit: -leukocytes ≥ 3,000/μl; -absolute neutrophil count ≥ 1,500/μl; -platelets ≥ 100,000/μl; -total bilirubin within N institutional limits; -AST(SGOT)/ALT(SGPT) ≤2.5 times institutional upper limit of N -creatinine within normal institutional limits; OR creatinine clearance ≥30 mL/min/1.73 m2 for pts with cr levels above normal; Inclusion Criteria

18. If female, postmenopausal for a min of one year, OR surgically sterile, OR not pregnant, confirmed by ß-HCG blood test, and willing to use adequate contraception Able to understand and willing to sign a written informed consent document and a HIPAA authorization in accordance with institutional guidelines Inclusion Criteria

19. Prior treatment (any) to the involved breast Uncontrolled intercurrent illness Medically unstable Unable to lie still for 1.5 hrs, requirement of anesthesia History of allergic reactions attributed to compounds of similar chemical or biologic composition to FLT Pregnant or nursing or age<18 Previous malignancy, other than basal cell or squamous cell carcinoma of the skin or in situ ca of the cervix, from which the patient has been disease free for < 5 years Currently on hormone therapy as a primary therapy (aside from hormonal replacement therapy) Exclusion Criteria

20. Study Calendar

21. Study Procedures • Visit 1: Screening visit • -screening assessment will occur to determine eligibility • -signed consent form will be obtained prior to study trial • CBC with differential and serum chemistry, and platelets. • If data available from clinical records in the appropriate time window, • they need not be repeated for pre-study evaluation. • -medical history, demographics, height, weight, and PE • -tissue samples/slides from bx will be sent to VCU Pathology • Visit 2:FLT PET Imaging Studies (FLT1) • -baseline FLT PET scan; within 4 wks prior to chemo • Visit 3: FLT PET Imaging Studies (FLT2) • -early therapy FLT PET;5-10 dys after the initiation of 1st cycle • Visit 4: FLT PET Imaging Studies (FLT-3) • post therapy FLT PET;after chemo & within 3wks prior to surgery • Visit 5: Surgery • -After neoadjuvant chemo, surgical resection of residual tm • -A portion of residual tm sample/slides will be sent for to VCU Core Pathology for pathologic analysis and proliferation assays within 2 wks post surgery • - If no viable tumor remains, a pCR will be documented

22. The participant will undergo [18F]FLT injection, immediately after injection a dynamic regional PET/CT imaging will be done for 60 minutes dynamic imaging will be followed by a static whole body image from top of head to upper thigh; 5-7 bed positions The preferred imaging sequence for the is to obtain the dynamic PET imaging first, then followed by the torso survey using static PET imaging, however, for patients  who are unable to tolerate lying in the scanner for dynamic imaging or for centers where scanner availability/scheduling is limited, the acquisition of the SUV using static PET imaging starting 60 minutes after injection fulfills the needs of the study. Analyses SUV30 Patlak slope SUV30-60 FluxFLT SUV60 k3 Imaging Sessions

23. FLT Parameters Compared To Pre-Rx (FLT1) parameters Ki-67/mit index, biopsy Clinical Response Path. Response (pCR and RCB) After one cycle (FL2) parameters Clinical Response (absolute values and % change from FLT1) Response from other imaging modalities (as available) Path Response (pCR and RCB) Post-therapy (FLT3) parameters Ki-67/mit index, surg spec (absolute values and % change from FLT1) Clinical Response Response from other imaging modalities (as available) Path. Response (pCR and RCB) Data Analysis

24. Pathologic Complete Response • pCR is defined as the absence of viable invasive tumor at histopathologic examination of the post-therapy surgical specimen • This analysis will be performed at the local treating site and reviewed at the central site at VCU • Presence of residual non-invasive cancer (DCIS) in the absence of viable invasive cancer is still considered a pCR • Dichotomous response assessment; pCR vs other than pCR •  A secondary related measure will also be assessed, the residual cancer burden (RCB) which will be used for secondary objectives (described in the protocol)

25. Clinical Response • Clinical Response as per routine by the treating physician based upon the % change in anatomic tm size between the pre, early-, and post-treatment time points • The assessment of size will be made per routine of the treating physician and will typically be performed by one of the following: PE, mammography, US, or breast MRI • The same method should be used consistently for each patient throughout this study. The categorization of clinical response is categorized as described in Table

26. Accrual Plot and Current Accrual Rate Last three months: Average 2 pts/month Last 3 months: Avg 2 pts/month

27. Participating Institutions and Accrual Status Opened Accrual

28. THANK YOU!