18F-FSPG PET/CT in Imaging Patients With Newly Diagnosed Lung Cancer or Indeterminate Pulmonary Nodules

PRIMARY OBJECTIVES:

I. To compare the imaging characteristics of 18F-FSPG PET/CT with standard-of-care, 18F-FDG PET/CT.

II. To compare the imaging characteristics of 18F-FSPG PET/CT to standard-of-care 18F-FDG PET/CT in patients with newly diagnosed lung cancer.

III. To determine whether 18F-FSPG uptake in lung cancer can be predicted based on correlation with CD44 and amino acid transport system xc- (xC-) expression in surgical pathology specimens.

OUTLINE:

Patients undergo 18F-FDG PET/CT scan per standard of care. Within 15 working days, patients also undergo 18F-FSPG PET scan over 60 minutes followed by an 18F-FSPG PET/CT scan over 30 minutes.

After completion of study, patients are followed up for 2 years if needed for diagnosis.

• Computed Tomography (Procedure), also known as CAT, CAT Scan, Computerized Axial Tomography, Computerized Tomography, CT, CT SCAN, tomography: Undergo 18F-FDG PET/CT - standard of care
• Computed Tomography (Procedure), also known as CAT, CAT Scan, Computerized Axial Tomography, Computerized Tomography, CT, CT SCAN, tomography: Undergo 18F-FSPG PET/CT
• fluorodeoxyglucose F-18 (Radiation), also known as 18FDG, FDG, Fluorine-18 2-Fluoro-2-deoxy-D-Glucose: Undergo 18F-FDG PET/CT - standard of care
• Fluorine F 18 L-glutamate Derivative BAY94-9392 (Drug), also known as (S)-4-(3-18F-fluoropropyl)-L-glutamic Acid, 18F-FSPG, BAY94-9392: Undergo 18F-FSPG PET/CT
• Laboratory Biomarker Analysis (Other): Correlative studies
• Positron Emission Tomography (Procedure), also known as Medical Imaging, Positron Emission Tomography, PET, PET SCAN, Positron Emission Tomography Scan, proton magnetic resonance spectroscopic imaging: Undergo 18F-FDG PET/CT - standard of care
• Positron Emission Tomography (PET) (Procedure), also known as Medical Imaging, Positron Emission Tomography, Positron Emission Tomography Scan, proton magnetic resonance spectroscopic imaging: Undergo 18F-FSPG PET/CT

Primary outcomes

• Ability of 18F-FSPG PET/CT to Discriminate Benign From Malignant Nodules [Up to 2 years]: Sensitivity, specificity, overall accuracy and receiver operating characteristic (ROC) curves will be generated and compared for both 18F-FDG and 18F-FSPG tests. Sensitivity is the proportion of High(positive) among cancer patients. Specificity is the proportion of low(negative) among benign tumors. Accuracy is the proportion of correctly diagnosed among analyzed patients. Area under the curve(AUC) is the area under the ROC curve, which is the plot of sensitivity by 1-specificity.

Secondary outcomes

• CD44 and xC- Expression Levels in Tissue Samples(0-3) [Up to 2 years]: The level of expression of xCT and CD44 proteins in the cytoplasmic membrane of tumor cells were examined by an experienced pathologist who was blinded to any patient and imaging information. The percentage of tumor cells positive for the marker and the intensity of staining were evaluated, the latter using a scale of 0 (none), 1+ (weak), 2+ (intermediate), and 3+ (strong) with a sample being reported as positive if greater than 10% of the tumor cells in the sample were positively stained with any intensity.
• Uptake of 18F-FSPG (Expressed in Maximal Standardized Uptake Value [SUV] Within the Tumor) [Up to 2 years]: Maximum standardized uptake values (SUVmax) were normalized to lean body mass and measured with a 1 cm diameter round region of interest over the area of greatest uptake in the lesion being measured.
• Ability of 18F-FSPG PET/CT to Stage of Lung Cancer (Metastatic or Not) [Up to 2 years]: Sensitivity, specificity, overall accuracy and ROC curves will be generated and compared for both 18F-FDG and 18F-FSPG tests. Wilcoxon rank-sum or Kruskal-Wallis tests will be applied for the group comparisons of the biodistribution characteristics of 18F-FDG and 18F-FSPG tests. Sensitivity is the proportion of High(positive) among cancer patients. Specificity is the proportion of low(negative) among benign tumors. Accuracy is the proportion of correctly diagnosed among all patients. Area under the curve(AUC) is the area under the ROC curve.

Other outcomes

• Uptake of 18F-FSPG (Expressed in Maximal Standardized Uptake Value [SUV] Within the [Up to 2 years]: Descriptive statistics, including means, standard deviations, and ranges for continuous

Sex: All, ages: 40 Years to 80 Years

Inclusion Criteria:

\- Have an indeterminate untreated pulmonary nodule (IPN) (7-30 mm diameter) on CT, or an indeterminate lung mass (> 30 mm diameter), without prior examinations that establish that the lesion has been stable for two or more years, untreated.

or

* Have a newly diagnosed, untreated primary lung cancer diameter 7 mm or more.
* Be able to give informed consent, which will include a layman's explanation of the estimated amount of additional radiation that the patient will receive from the investigational PET/CT scan using 18F-FSPG
* Must agree at the time of study entry to undergo clinically indicated biopsy(ies) or a 24-month period of follow-up, as needed, to resolve the etiology of their IPN(s) or lung mass(es).

Exclusion Criteria:

* Pregnant or lactating patients will be excluded, as will females of childbearing potential who refuse to undergo a serum or urinary beta-HCG pregnancy test the day of either the 18F-FSPG or the 18F-FDG PET/CT scans, in accordance with the standard policy of the Medical Imaging Service at our facility. Women who have experienced 24 consecutive months of amenorrhea, have reached at least 60 years of age, or have had a tubal ligation or hysterectomy documented in their medical records are considered not to be of childbearing potential for the purposes of this protocol
* Patients with a body weight of 400 pounds or more or a body habitus or disability that will not permit the imaging protocol to be performed
* A recognized active lung infection
* Previous systemic or radiation treatment for cancer of any type within 1 year
* For patients who do not have a tissue diagnosis:

  * Non-oncologic severe co-morbidities suggesting a life span of less than two years if not treated, as determined by the potential subject's treating physician.

Participant flow

Outcome results

• Ability of 18F-FSPG PET/CT to Discriminate Benign From Malignant Nodules (Primary), Number, proportion, range 0 to 1, higher better: Diagnostic (18F-FDG PET/CT, 18F-FSPG PET/CT) 0.706 (0.489 to 0.922)
• CD44 and xC- Expression Levels in Tissue Samples(0-3) (Secondary), Mean, IHC score, range 0 and above: Some Cancer Patients 2.6 +/- 0.5
• Uptake of 18F-FSPG (Expressed in Maximal Standardized Uptake Value [SUV] Within the Tumor) (Secondary), Mean, Maximum standardized uptake values (SUVm: Benign Patients 0.8 +/- 0.7; Cancer Patients 3.9 +/- 3.6
• Ability of 18F-FSPG PET/CT to Stage of Lung Cancer (Metastatic or Not) (Secondary), Number, proportion, range 0-1, higher better: Diagnostic (18F-FDG PET/CT, 18F-FSPG PET/CT) 0.8 (0.552 to 1)
• Uptake of 18F-FSPG (Expressed in Maximal Standardized Uptake Value [SUV] Within the (Other pre specified)

Adverse events

Time frame: From study entry to approximately 60 days

Serious adverse events by term

Other adverse events by term

• Study Protocol and Statistical Analysis Plan (PDF, 2021-04-06)

• Chirayu Shah, MD, Principal investigator, Vanderbilt-Ingram Cancer Center

NIH grants: P30CA068485