Phase II Study Evaluating Confocal Endoscopic Microscopy for Detection of Early Stage Gastric Cancer in Subjects With Hereditary Diffuse Gastric Cancer Syndrome
Phase: PHASE2
Conditions: Gastric Cancer, Gastric Neoplasms
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: CEM in subjects with HDGC 
Version Date:  06/05/2019 
 
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Abbreviated Title: CEM in subjects with HDGC 
CC Protocol #: 18C0141 C 
Version Date: 06/05/2019 
NCT Number #: NCT03648879 
 
Title: Phase II Study Evaluating Confocal Endoscopic Microscopy for Detection of Early Stage 
Gastric Cancer in Subjects with Hereditary Diffuse Gastric Cancer Syndrome 
 
NCI Principal Investigator: 
Jeremy L. Davis, MD 
 Surgical Oncology Program (SOP), CCR, NCI, NIH 
Building 10, Room 4-3760 
10 Center Drive 
Bethesda, MD 20892 
Phone: 240-760-6229 
Email: jeremy.davis@nih.gov 
 
Commercial Devices:  
• Cellvizio® 100 series systems with confocal miniprobes™ (Mauna Kea Technologies) 
• Olympus GIF 180 endoscope (Global Endoscopy Solutions) 

Abbreviated Title: CEM in subjects with HDGC 
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PRÉCIS 
Background: 
• Hereditary Diffuse Gastric Cancer (HDGC) syndrome is caused by a germline mutation 
in the CDH1 gene. Carriers of this mutation have a 56-70% lifetime risk of developing 
gastric adenocarcinoma. Current international guidelines recommend endoscopic 
screening of CDH1 mutation carriers that consists of systematic biopsies of an otherwise 
normal appearing stomach. However, this approach lacks sufficient sensitivity for 
detecting intramucosal foci of signet ring cells (SRC), which are pathognomonic of 
HDGC syndrome. The goal of the current study is to utilize confocal endoscopic 
microscopy (CEM) for screening the gastric mucosa in this high-risk population. 
Objective: 
• Determine if confocal endoscopic microscopy (CEM) will afford greater sensitivity for 
detection of SRC foci in CDH1 germline mutation carriers. 
Eligibility: 
• CDH1 germline mutation carriers, or those who meet clinical criteria for HDGC testing 
but have tested negative for a CDH1 gene mutation or those who have other germline 
mutations suspected to be, or reported to be, associated with HDGC (e.g. CTNNA1). 
Design: 
• Phase II, single-institution study of CEM for detection of intramucosal SRC foci 
compared to current systematic gastric mapping procedure.  

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TABLE OF CONTENTS  
PRÉCIS ........................................................................................................................................... 2 
TABLE OF CONTENTS ................................................................................................................ 3 
1 
INTRODUCTION .................................................................................................................. 6 
1.1 
Study Objectives .............................................................................................................. 6 
1.1.1 
Primary Objective ..................................................................................................... 6 
1.1.2 
Secondary Objective ................................................................................................. 6 
1.2 
Background and Rationale ............................................................................................... 6 
1.2.1 
Rationale for Confocal Endoscopic Microscopy ...................................................... 8 
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT ....................................................... 10 
2.1 
Eligibility Criteria .......................................................................................................... 10 
2.1.1 
Inclusion Criteria .................................................................................................... 10 
2.1.2 
Exclusion Criteria ................................................................................................... 11 
2.1.3 
Recruitment Strategies ............................................................................................ 11 
2.2 
Screening Evaluation...................................................................................................... 11 
2.3 
Registration Procedures.................................................................................................. 11 
2.3.1 
Intervention Assignment Procedures (For Registration Purposes Only): ............... 11 
2.4 
Baseline Evaluation ........................................................................................................ 12 
3 
STUDY IMPLEMENTATION ............................................................................................ 12 
3.1 
Study Design .................................................................................................................. 12 
3.2 
Surgical Guidelines ........................................................................................................ 12 
3.2.1 
Preoperative Patient Management .......................................................................... 12 
3.2.2 
White-light, Upper Endoscopy ............................................................................... 12 
3.2.3 
CEM Analysis ......................................................................................................... 13 
3.2.4 
Postoperative Care .................................................................................................. 13 
3.2.5 
Discharge ................................................................................................................ 13 
3.2.6 
Post-discharge/Follow-up ....................................................................................... 13 
3.3 
Criteria for Removal from Protocol Interventions and Off Study Criteria .................... 13 
3.3.1 
Criteria for Removal from Protocol Interventions .................................................. 13 
3.3.2 
Off-Study Criteria ................................................................................................... 14 
3.3.3 
Off Protocol Intervention and Off-Study Procedure ............................................... 14 
4 
CONCOMITANT MEDICATIONS/MEASURES .............................................................. 14 

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5 
BIOSPECIMEN COLLECTION .......................................................................................... 14 
5.1 
Sample Storage, Tracking and Disposition .................................................................... 14 
5.1.1 
Procedures for Storage of Tissue Specimens in the Laboratory of Pathology ....... 14 
5.1.2 
Protocol Completion/Sample Destruction .............................................................. 15 
6 
DATA COLLECTION AND EVALUATION ..................................................................... 15 
6.1 
Data Collection ............................................................................................................... 15 
6.2 
Data Sharing Plans ......................................................................................................... 16 
6.2.1 
Human Data Sharing Plan ....................................................................................... 16 
6.2.2 
Genomic Data Sharing Plan .................................................................................... 16 
6.3 
Toxicity Criteria ............................................................................................................. 16 
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN .... 16 
7.1 
Definitions ...................................................................................................................... 16 
7.2 
OHSRP Office of Compliance and Training / IRB Reporting ....................................... 17 
7.2.1 
Expedited Reporting ............................................................................................... 17 
7.2.2 
IRB Requirements for PI Reporting at Continuing Review ................................... 17 
7.3 
NCI Clinical Director Reporting .................................................................................... 17 
7.4 
NIH Required Data and Safety Monitoring Plan ........................................................... 17 
7.4.1 
Principal Investigator/Research Team .................................................................... 17 
8 
STATISTICAL CONSIDERATIONS.................................................................................. 17 
8.1 
STATISTICAL HYPOTHESIS ..................................................................................... 17 
8.2 
Sample Size Determination ............................................................................................ 18 
8.3 
Populations for Analyses ................................................................................................ 18 
8.4 
STATISTICAL ANALYSES ................................................................................................ 18 
8.4.1 
Analysis of the Primary Endpoints ......................................................................... 18 
8.4.2 
Analysis of the Secondary Endpoint(s)................................................................... 18 
9 
HUMAN SUBJECTS PROTECTIONS ............................................................................... 19 
9.1 
Rationale for Subject Selection ...................................................................................... 19 
9.2 
Participation of Children ................................................................................................ 19 
9.3 
Participation of Subjects Unable to Give Consent ......................................................... 19 
9.4 
Participation of Pregnant Women .................................................................................. 19 
9.5 
Evaluation of Benefits and Risks/Discomforts .............................................................. 19 
9.5.1 
Risks for All Participants Including Subjects Unable to Consent .......................... 20 

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9.5.2 
Benefits for All Participants Including Subjects Unable to Consent ...................... 20 
9.5.3 
Risk/Benefit Analysis for Pregnant Women ........................................................... 20 
9.6 
Consent Process and Documentation ............................................................................. 20 
9.6.1 
Telephone Consent.................................................................................................. 20 
10 DEVICE INFORMATION ................................................................................................... 21 
10.1 
Source ......................................................................................................................... 21 
11 REFERENCES ..................................................................................................................... 22 
12 Appendices ............................................................................................................................ 24 
12.1 
Appendix A: Clinical Criteria for Genetic Testing Due to a History Suggestive of 
Hereditary Diffuse Gastric Cancer (HDGC) Syndrome ........................................................... 24 
 

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1 
INTRODUCTION 
1.1 
STUDY OBJECTIVES 
1.1.1 Primary Objective 
• Determine if confocal endoscopic microscopy (CEM) will afford greater sensitivity for 
detection of SRC foci in CDH1 germline mutation carriers compared to the current 
method. 
1.1.2 Secondary Objective 
• Define the false negative rate of CEM detection of SRC foci in those patients who choose 
to undergo prophylactic total gastrectomy with permanent pathologic analysis.  
1.2 
BACKGROUND AND RATIONALE 
Although gastric adenocarcinoma represents 1.7% of all new cancer cases in the United States it 
is the fifth most common cancer worldwide.[1, 2] Environmental influences such as H. pylori 
infection, tobacco smoking, and dietary factors are common risk factors for developing gastric 
cancer. Hereditary causes account for 1-3% of gastric cancer cases globally. The three main 
heritable forms of gastric cancer are hereditary diffuse gastric cancer (HDGC) syndrome, gastric 
adenocarcinoma and proximal polyposis of the stomach (GAPPS), and familial intestinal gastric 
cancer (FIGC). The commonest example of inherited gastric cancer, HDGC, imparts a 56-70% 
lifetime risk of developing diffuse gastric cancer, and a 42% risk of developing lobular breast 
cancer in female carriers.[3, 4] The five-year overall survival rate for patients diagnosed with 
invasive gastric cancer in the United States is 30%.  
HDGC is an autosomal dominant syndrome that is due to a mutation in the CDH1 gene.[4] The 
CDH1 gene encodes the glycoprotein E-cadherin, which is located on the surface of epithelial 
cells at the adherens junctions. It plays a crucial role in cell to cell adhesion and communication 
through homotypic interactions via the extracellular domain. Reduced expression of E-cadherin, 
often via mutation of the CDH1 gene, interferes with the integrity of the adherens junctions and 
loss of epithelial architecture, cell polarity, and cell-cell adhesion. Cancer cells with metastatic 
potential often demonstrate a loss of E-cadherin-mediated cell adhesion. This is how the CDH1 
gene came to be known as a tumor suppressor gene.[5] There are more than 100 known 
pathogenic germline mutations of the CDH1 gene.[6] 
For patients diagnosed with a pathogenic germline CDH1 mutation, a risk-reducing total 
gastrectomy is recommended. This is because mutation carriers are often found to have occult, 
early-stage (T1a) gastric cancers not visible on routine upper endoscopy. Risk-reducing total 
gastrectomy is recommended after the age of 20 or 5 years earlier than the age of diagnosis of the 
youngest affected family member. In addition, initial upper endoscopic gastric screening is 
recommended in all patients diagnosed with CDH1 mutation. For patients that choose not to 
proceed with a risk-reducing gastrectomy, annual endoscopic surveillance is currently 
recommended.[4, 7] Endoscopy should be done under white light with a high-definition 
endoscope. The International Gastric Cancer Linkage Consortium (IGCLC) recommendation is 
for six biopsies from each anatomical zone of the stomach (antrum, transitional zone, body, 
fundus, and cardia) and any visible lesion.[8] If any of the biopsies show signet ring cells on 
pathology then the patient is advised to undergo a therapeutic total gastrectomy.  

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Total gastrectomy to reduce gastric cancer risk remains a strong recommendation not only 
because of the lethality of invasive gastric cancer, but also because cancer screening with 
endoscopy is ineffective for detecting early, occult gastric cancers. In previously published series 
of HDGC syndrome patients, signet ring cell foci are reported to make up less than 2% of the 
gastric mucosa and are often less than 1 mm in diameter.[9] Gastric adenocarcinomas in HDGC 
syndrome patients are characterized by diffuse-type histology of signet ring cells, often with 
multiple foci throughout the gastric mucosa. Endoscopy rarely shows gross abnormalities or 
tumor masses, even though random biopsies have been known to demonstrate intramucosal foci 
of signet ring cells. Alternative visual enhancement with endoscopy has also been studied, 
including narrow band imaging, chromoendoscopy, and utilization of Congo red and indigo-
carmine dyes.[10, 11] None of these enhancements has led to significantly increased rates of 
detection. Thus, better screening modalities are needed.  
Our group has substantial experience evaluating HDGC syndrome patients with data that support 
the inadequacy of current endoscopic surveillance methods. As of November 2017, we evaluated 
54 patients with predisposition to gastric malignancy at the NIH. Of the 54 patients evaluated, 40 
(74%) had a primary genetic abnormality predisposing to gastric malignancy with the remainder 
having strong family history. All patients were Caucasian, with a majority being female (66%) 
and a mean age of 44 years. Subjects were screened either through standard upper endoscopy 
(EGD) with a combination of random and targeted biopsies, or later through a systematic gastric 
mapping protocol developed by Yao.[12] Of the 56 EGDs performed, 17 (30%) were performed 
via detailed gastric mapping with resultant 88 individual biopsies in 22 distinct locations in the 
stomach. Of the remaining 39 (70%) standard EGDs, targeted biopsies of endoscopic 
abnormalities and random biopsies from the antrum and body were performed. In subjects 
undergoing systematic gastric mapping, signet ring cells were identified in 4 patients (24%), 
whereas all 39 standard EGD biopsies were absent of signet ring cells (0%). With regard to long-
term follow up, in 22 patients that subsequently underwent prophylactic total gastrectomy, 
malignancy was identified by histology in 12 (55%) of cases. In the 4 subjects that underwent 
systematic gastric mapping followed by total gastrectomy, biopsies obtained during gastric 
mapping matched gastrectomy specimen pathology in all cases (100%). Comparatively, in the 18 
subjects that underwent standard endoscopy and gastrectomy, 8 cases of malignancy were 
identified on gastrectomy specimen pathology (44%). See flowchart below. These preliminary 
results suggest that while comprehensive gastric mapping biopsies may be superior at detecting 
early malignancy when compared to standard EGD, the overall detection rate remains too low to 
recommend surveillance over prophylactic total gastrectomy with confidence.  

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Similarly, a retrospective study of 23 patients with a CDH1 mutation also demonstrated that 
EGD is not an adequate screening modality. Of the 23 patients, only 2 were found to have SRC 
foci on EGD with biopsy. All 23 patients underwent a prophylactic total gastrectomy. On final 
pathology, 22/23 patients were found to have foci of SRCs. This means that screening with EGD 
only had a detection rate of 9%.[13]  
1.2.1 Rationale for Confocal Endoscopic Microscopy 
Confocal endoscopic microscopy (CEM) allows physicians to obtain in vivo histology images of 
the gastrointestinal mucosa. CEM consists of using the tissue’s own fluorescent ability or the aid 
of an IV contrast agent. Contrast will highlight the vasculature, lamina propria, and intracellular 
spaces allowing for the architecture of each cell to be visualized.[14] A fiber optic bundle with 
an integrated distal lens is passed through the endoscope channel and connected to a laser 
scanning unit. This system has a fixed focal length so it scans in only one plane. The GastroFlex 
probe requires a ≥ 2.8 mm channel. It has a field of view of 250 micrometers, resolution of 1 
micrometer, and confocal depth of 55 – 65 micrometers. Each probe can be used on 20 patients. 
The system is compatible with a standard endoscope. The advantage of a confocal laser 
microscope is that it is efficient at eliminating out of focus fluorescent light and creating a clear 
image from a sample. Based on multiple Japanese reports, cancer cells can be distinguished from 
those of normal mucosa by irregular nuclear size and shape. CEM correlated with H&E stained 
images.[15] Kitabatake and colleagues used CEM in vivo and found that the confocal images of 
gastric cancer differed from normal mucosa, which was confirmed with H&E staining. This 
study also found variability in gastric mucosa affected image capture, but that application of oral 
pronase and sodium hydrogen carbonate as pretreatment could reduce that variability.[16] 
CEM has been used for gastric cancer screening and in a variety of other gastrointestinal 
neoplastic diseases. Specifically, CEM has been used in patients with intestinal metaplasia of the 
gastric epithelium and for detection of very early stage gastric cancers in Asian patients. One of 
the largest studies published to date, the sensitivity and specific of CEM was 89% and 99%, 
respectively, in detecting superficial cancers and high-grade intraepithelial neoplasia. To the best 

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of our knowledge, the proposed study is the first time that CEM will be used as a screening 
modality in patients with pathogenic germline CDH1 mutations.  
Most patients with a CDH1 mutation develop multifocal, occult tumors throughout the gastric 
mucosa with the ability for further invasion and metastatic spread.[17] Since patients already 
have a CDH1 mutation in one allele, they develop these islands of microscopic signet ring cells 
due to inactivation of the second allele. Studies have demonstrated that the remaining CDH1 
wild type allele may become inactivated through hypermethylation of the CDH1 promoter.[18-
20] However, another study found frequently more than one inactivating mechanism of the 
second allele within the same patient.[21] The H&E photomicrograph below is from a surgical 
gastrectomy specimen and demonstrates signet ring cells (black arrow) within the lamina propria 
of the gastric mucosa of a patient with a pathogenic CDH1 mutation. 
 
Aside from loss of CDH1 gene expression in HDGC patients with early-stage, signet ring cell 
cancers, little is known about subsequent genomic (or epigenomic) events that lead to gastric 
cancer growth, invasion or metastasis. However, compelling in vitro and pre-clinical data 
suggest specific additional molecular alterations required for cancer progression beyond the 
intra-mucosal signet ring cell stage. Humar and colleagues have proposed activation of c-Src and 
its downstream targets correlates well with cancer progression and the differentiated cancer cell 
phenotype in early HDGC.[22] c-Src is known to elevate the expression of β-catenin and 
activation of the Wnt pathway in the epithelial-to-mesenchymal transition cell phenotype.[23] 

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Another potential molecular driver of diffuse-type gastric cancers includes gain of function 
RHOA gene mutations that have been described in multiple genomic analyses.[24, 25] Gene 
expression analysis of gastric signet ring cells from CDH1 patients will likely provide insight 
into the stepwise progression of gastric cancer. Elucidating the genomic hits necessary for gastric 
cancer progression and metastasis may demonstrate potential therapeutic targets. 
In this study we are going to use Cellvizio® 100 Series systems with Confocal Miniprobes™. 
These are confocal laser systems with fiber optic probes, approved by FDA, that are intended to 
allow imaging of the internal microstructure of tissues including, but not limited to, the 
identification of cells and vessels and their organization or architecture. Prior to patient 
enrollment in this study, the principal investigator and lead associate investigators have 
evaluated the CEM probe used in a clinical setting. In addition, ex vivo application of the CEM 
probe to gastric tissue is planned for training of associate investigators. Since many patients 
undergo total gastrectomy at the NIH Clinical Center, the CEM probe can be used to scan the 
mucosa of explanted gastrectomy specimens. While this CEM training is not part of the study, it 
is designed to ensure proper calling of normal and abnormal mucosal images obtained by the 
CEM probe. There are no inherent risks to the use of the CEM probe per se. Rather, standard 
training in upper endoscopy should be requisite for use of the CEM probe. 
The goal of this study is to determine if CEM will afford a higher level of sensitivity for 
detection of signet ring cell cancers in CDH1 germline mutation carriers. This technology will be 
compared to traditional endoscopic surveillance and gastric mapping (consisting of multiple 
biopsies from each area of the stomach) for patients with a pathogenic CDH1 germline mutation. 
It is hoped that this technique may lead to fewer gastric biopsies required and a more sensitive 
way to screen for SRC in patients with CDH1 mutation.  
2 
ELIGIBILITY ASSESSMENT AND ENROLLMENT  
2.1 
ELIGIBILITY CRITERIA 
2.1.1 Inclusion Criteria 
➢ Patients with CDH1 germline mutation known to be pathogenic or likely pathogenic, 
which may also be classified as “significant” or “likely significant” (patients with 
variants of “uncertain significance” are excluded). 
or 
➢ Patients with CTNNA1 and PALB2 germline mutations suspected to be, or reported to 
be, associated with HDGC.  
or 
➢ In the absence of a germline CDH1 mutation, patients must meet clinical criteria for 
genetic testing due to a history suggestive of Hereditary Diffuse Gastric Cancer (HDGC) 
syndrome (Appendix A). 
➢ Age >18 years.  
➢ Physiologically able to undergo upper endoscopy.  
➢ Ability to understand and the willingness to sign a written informed consent document. 

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➢ Pregnant women are eligible during second trimester of pregnancy if clinically indicated 
for evaluation of cancer. 
2.1.2 Exclusion Criteria 
➢ Current use of therapeutic anticoagulation medication. 
➢ Known bleeding disorder or thrombocytopenia. 
➢ Unstable angina or recent (within 3 months) myocardial infarction.  
➢ Any clinical contraindication to general anesthesia. 
2.1.3 Recruitment Strategies 
This study will be posted on NIH websites, NIH social media forums, the CCR website and on 
clinicaltrials.gov. Participants may also be recruited through self-referrals, physician referrals, 
and referrals from the NIH Clinical Center (CC) Office of Patient Recruitment. 
2.2 
SCREENING EVALUATION 
Within 28 days prior to enrollment unless otherwise noted below: 
➢ Complete medical history and physical examination, including vital signs. 
➢ Review of genetic test results performed in CLIA-approved lab.  
2.3 
REGISTRATION PROCEDURES 
Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) 
within 24 hours of signing consent. A registration Eligibility Checklist from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 
encrypted email to: NCI Central Registration Office ncicentralregistration-l@mail.nih.gov. After 
confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to advise 
them of the acceptance of the patient on the protocol prior to the release of any investigational 
agents. Verification of Registration will be forwarded electronically via e-mail to the research 
team. A recorder is available during non-working hours.  
2.3.1 Intervention Assignment Procedures (For Registration Purposes Only): 
Cohorts 
Number Name 
Description 
1 
Cohort 1 
Subjects with CTNNA1, PalB2 or known to be pathogenic or likely 
pathogenic CDH1 germline mutations, or those who test negative for 
these mutations, but meet clinical criteria for HDGC.  
 
Arms 
Number Name 
Description 
1 
Arm 1 
Upper white-light endoscopy and confocal endoscopic microscopy 

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Arm Assignment 
Subjects in Cohort 1 will be directly assigned to Arm 1. 
2.4 
BASELINE EVALUATION 
Within 28 days prior to study procedure (does not need to be repeated if performed during 
Screening within designated time period): 
➢ Physical examination, including weight and vital signs.  
3 
STUDY IMPLEMENTATION 
3.1 
STUDY DESIGN 
This is a Phase II single arm study designed to evaluate the efficacy of CEM to detect signet ring 
cell foci within the gastric mucosa of patients with hereditary diffuse gastric cancer syndrome. 
At the time of endoscopy, all patients will undergo white-light, upper endoscopy with systematic 
gastric mapping according to our current practice pattern and as outlined by IGCLC [12] 
(Section 3.2.2). In addition, during this endoscopy patients will undergo CEM using the 
Cellvizio probe (Mauna Kea Technologies) to scan the same anatomic zones as evaluated in the 
systematic gastric mapping approach (Section 3.2.3). Any abnormal areas visualized with the 
CEM probe will be biopsied. Patients are informed of the risks of endoscopy such as 
gastrointestinal bleeding and perforation. The standard gastric mapping requires approximately 
30 minutes of general anesthesia time. The addition of CEM adds another 30 minutes of general 
anesthesia but no increase in risk of general complications such as bleeding or perforation.  
All biopsies are sent to Laboratory of Pathology (see Section 5.1.1). In patients co-enrolled to 
protocol 13C0176, leftover biopsy samples will be used for research as described in 13C0176.  
3.2 
SURGICAL GUIDELINES  
3.2.1 Preoperative Patient Management  
Patients will receive standard preoperative care as appropriate to the planned endoscopic 
intervention and the patient’s underlying health status. This will include sequential compression 
devices placed on the lower extremities prior to induction of general anesthesia. 
3.2.2 White-light, Upper Endoscopy  
At the time of endoscopy, all patients will undergo white-light, upper endoscopy with systematic 
gastric mapping according to IGCLC guidelines.[8] The anatomic zones are outlined below. 
From each of the five zones, 6 cold forceps biopsies and photos will be obtained. The total 
number of biopsies will be thirty. Any visibly abnormal areas will also biopsied.   
1. Antrum  
2. Transitional Zone (antrum-body)  
3. Body  
4. Fundus 

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5. Cardia  
3.2.3 CEM Analysis 
Patients will also undergo CEM analysis of gastric zones using the Cellvizio probe (Mauna Kea 
Technologies). Abnormal mucosa visualized will have images digitally captured and biopsied. 
• Antrum (antegrade view): 4 quadrants (Anterior [A], Lesser curve [L], Posterior [P], 
Greater curve [G]) 
• Lower body (antegrade view): 4 quadrants [A, L, P, G] 
• Middle-upper body (antegrade view): 4 quadrants [A, L, P, G] 
• Fundus-cardia (retroflex view): 4 quadrants [A, L, P, G] 
• Middle-upper body (retroflex view): 3 quadrants [A, L, P] 
• Incisura (retroflex view): 3 quadrants [A, L, P] 
Patients will receive the contrast agent fluorescein prior to endoscopy if no known allergy to 
fluorescein is documented. Patients who cannot receive fluorescein (e.g. pregnancy or allergy) 
will have CEM performed in the absence of this contrast agent. 
3.2.4 Postoperative Care 
• Patients will be monitored in the post anesthesia care unit (PACU) after their procedure 
prior to being discharged (if outpatient) or transferred to the inpatient ward (if inpatient). 
3.2.5 Discharge 
• Total hospitalization may be 0-1 day. If patients live in the area they may come in the 
morning of the procedure and leave on the same day providing they have a companion 
with them. If the patient is traveling from afar then they will spend the night in the 
hospital after the procedure prior to going discharge.  
3.2.6 Post-discharge/Follow-up 
• Patients will return to the NIH Clinical Center approximately two weeks after the EGD to 
discuss pathology results and any adverse events that they might have experienced. 
Alternatively, we will discuss pathology results and AEs on the phone.  
• If patient elects to undergo gastrectomy, we will request stomach tissue to perform 
pathology assessment. 
3.3 
CRITERIA FOR REMOVAL FROM PROTOCOL INTERVENTIONS AND OFF STUDY CRITERIA 
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 14 days following study interventions. 
3.3.1 Criteria for Removal from Protocol Interventions 
• Completion of protocol interventions 
• Patient requests to be withdrawn from active intervention 
• A serious or intolerable event related to the intervention occurs   

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• Investigator discretion 
3.3.2 Off-Study Criteria 
• Investigator discretion 
• Death 
• Participant requests to be withdrawn from study 
• Loss of follow up 
• PI decision to close the study 
3.3.3 Off Protocol Intervention and Off-Study Procedure 
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off 
protocol-intervention and when a subject is taken off-study. A Participant Status Update Form 
from the web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be 
completed 
and 
sent 
via 
encrypted 
email 
to: 
NCI 
Central 
Registration 
Office 
ncicentralregistration-l@mail.nih.gov. 
4 
CONCOMITANT MEDICATIONS/MEASURES 
During post-operative period, patients will receive all standard of care supportive measures, 
including pain control and incentive spirometry to prevent atelectasis as indicated.  
5 
BIOSPECIMEN COLLECTION 
Standard pathology evaluation of stomach tissue from biopsies and/or gastrectomy will be 
performed in the Laboratory of Pathology (see Section 5.1.1).  
Any leftover tissues, and gastric lavage fluid, collected for research, will be processed and stored 
on protocol 13C0176 if subject is co-enrolled on that study. 
5.1 
SAMPLE STORAGE, TRACKING AND DISPOSITION 
Samples will be ordered in CRIS Screens and tracked through a Clinical Trial Data Management 
system. Should a CRIS screen not be available, the CRIS downtime procedures will be followed. 
Samples will not be sent outside NIH without IRB notification and an executed MTA. 
5.1.1 Procedures for Storage of Tissue Specimens in the Laboratory of Pathology 
Tissues designated for clinical diagnostics are transported to the Laboratory of Pathology (LP) 
where they are examined grossly, and relevant portions are fixed, embedded in paraffin and 
sectioned and stained for diagnostic interpretation. Unutilized excess tissue that is not embedded 
in paraffin is stored in formalin for up to three months, in accordance with College of American 
Pathologists/Joint Commission on Accreditation of Healthcare Organizations (CAP/JCAHO) 
guidelines, and then discarded. Following completion of the diagnostic workup, the slides and 
tissue blocks are stored indefinitely in the LP’s clinical archives. All specimens are catalogued 
and retrieved utilizing the clinical laboratory information systems, in accordance with 
CAP/JCAHO regulations. The use of any stored specimens for research purposes is only allowed 
when the appropriate IRB approval has been obtained and subjects have been co-enrolled on 
protocol 13C0176. In some cases, this approval has been obtained via the original protocol on 
which the patient was enrolled. 

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5.1.2 Protocol Completion/Sample Destruction 
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that 
are remaining at the completion of the protocol will be stored in the conditions described in 
sections above. The study will remain open so long as sample or data analysis continues. 
Samples from consenting subjects will be stored until they are no longer of scientific value or if a 
subject withdraws consent for their continued use, at which time they will be destroyed. If the 
patient withdraws consent the participant’s data will be excluded from future distributions, but 
data that have already been distributed for approved research use will not be able to be retrieved. 
The PI will record any loss or unanticipated destruction of samples as a deviation. Reports will 
be made per the requirements of section 7.2.  
. 
6 
DATA COLLECTION AND EVALUATION  
6.1 
DATA COLLECTION 
The PI will be responsible for overseeing entry of data into an in-house password protected 
electronic system (Labmatrix) and ensuring data accuracy, consistency and timeliness. The 
principal investigator, associate investigators/research nurses and/or a contracted data manager 
will assist with the data management efforts. All data obtained during the conduct of the protocol 
will be kept in secure network drives or in approved alternative sites that comply with NIH 
security standards. Primary and final analyzed data will have identifiers so that research data can 
be attributed to an individual human subject participant. 
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event.  
Document AEs from the study procedure (see Section 3.2) through 14 days following study 
interventions. 
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following: 
• 
Results in discontinuation from the study 
• 
Is associated with clinical signs or symptoms  
• 
Requires treatment or any other therapeutic intervention 
• 
Is associated with death or another serious adverse event, including hospitalization.  
• 
Is judged by the Investigator to be of significant clinical impact 
• 
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome. 
Adverse Events related to endoscopy will only be recorded if they are serious (all Grades) or 
unexpected (Grades 3 and above).  
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable.  

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Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in Section 7.2.1.  
6.2 
DATA SHARING PLANS 
6.2.1 Human Data Sharing Plan 
What data will be shared? 
I will share human data generated in this research for future research as follows: 
• Coded, linked data in an NIH-funded or approved public repository. 
• Coded, linked data in another public repository. 
• Coded, linked data in BTRIS (automatic for activities in the Clinical Center). 
• Identified or coded, linked data with approved outside collaborators under appropriate 
agreements. 
How and where will the data be shared?  
Data will be shared through: 
• An NIH-funded or approved public repository, clinicaltrials.gov. 
• BTRIS (automatic for activities in the Clinical Center).  
• Publication and/or public presentations. 
When will the data be shared?  
• Before publication. 
• At the time of publication or shortly thereafter.  
6.2.2 Genomic Data Sharing Plan  
No genomic data will be collected. 
6.3 
TOXICITY CRITERIA 
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study. The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE 
reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 
5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_50).  
7 
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN 
7.1 
DEFINITIONS 
Please refer to definitions provided in Policy 801: Reporting Research Events found here. 

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7.2 
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING 
7.2.1 Expedited Reporting 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802: Non-Compliance Human Subjects Research found here.  
• 
Reports referenced in Policy 801 are made to the IC Specific IRB rather than to the 
OHSRP Office of Compliance and Training.   
• 
Section 5.2 of the Policy 801 does not apply. 
• 
Policy 802 does not apply. 
7.2.2  IRB Requirements for PI Reporting at Continuing Review 
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here. 
7.3 
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reported to the OHSRP/IRB in iRIS will also be reported to the NCI 
Clinical Director.  A separate submission is not necessary as reports in iRIS will be available to 
the Clinical Director. 
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to 
progressive disease.   
To report these deaths, please send an email describing the circumstances of the death to Dr. 
Dahut at NCICCRQA@mail.nih.gov within one business day of learning of the death. 
7.4 
NIH REQUIRED DATA AND SAFETY MONITORING PLAN 
7.4.1 Principal Investigator/Research Team  
The clinical research team will meet on a regular basis (weekly) when patients are being actively 
treated on the trial to discuss each patient.  
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in 
Section 7.2.1 will be submitted within the appropriate timelines.  
The principal investigator will review adverse event on each patient to ensure safety and data 
accuracy. The principal investigator will personally conduct or supervise the investigation and 
provide appropriate delegation of responsibilities to other members of the research staff.  
8 
STATISTICAL CONSIDERATIONS  
8.1 
STATISTICAL HYPOTHESIS 
Primary Endpoint:  
➢ Determine if confocal endoscopic microscopy (CEM) affords greater sensitivity for 
detection of SRC foci in CDH1 germline mutation carriers compared to the current 
method of standard white light endoscopy. 

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Secondary Endpoint: 
➢ Define the false negative rate of CEM detection of SRC foci in those patients who choose 
to undergo prophylactic total gastrectomy with permanent pathologic analysis.  
8.2 
SAMPLE SIZE DETERMINATION 
Subjects who are carriers of a CDH1 mutation and participate in this trial will undergo an EGD 
and detailed gastric mapping along with confocal laser microscopy. Based on the historical data 
from NIH, 17 patients who were CDH1 mutation carriers and who underwent an EGD and 
detailed gastric mapping resulted in 4 with signet ring foci detected. All 4 of these patients 
eventually were found to have gastric cancer after undergoing a prophylactic gastrectomy. An 
additional 18 patients who had prophylactic gastrectomy out of 39 who had conventional random 
biopsies yielded 8 patients with gastric cancer.  
Based on the current historical rate of 4/17 (23.5%) of mapped patients who had signet ring foci 
detected, it would be desirable to see if use of confocal laser microscopy could increase this 
detection rate substantially. With 36 patients undergoing EGD with detailed gastric mapping and 
confocal laser microscopy, there would be 89% power to rule out a 24% rate of signet ring 
detection in favor of a rate of detection consistent with 45%, with a one-sided 0.10 significance 
level exact binomial test. In practice, if 36 patients would undergo the procedure described and if 
13/36 (36.1%) would have signet ring foci identified, then the lower one-sided 90% confidence 
bound on 13/36 is 25.3%, which would demonstrate statistically greater detection in the subjects 
tested compared to the historical fraction of 4/17 (23.5%). In addition, the upper one-sided 90% 
confidence bound on 13/36 is 48.2%, which demonstrates that 13/36 could be shown to be 
consistent with as great as a 45% detection rate. 
It is expected that 18-20 patients may enroll on this study per year. Thus, to enroll 36 evaluable 
patients, approximately 24 months is the expected accrual period. To allow for a small number of 
inevaluable patients, the accrual ceiling will be set at 40 patients. 
8.3 
POPULATIONS FOR ANALYSES 
All patients who undergo an EGD and gastric mapping along with confocal endoscopic 
microscopy. 
8.4 
STATISTICAL ANALYSES 
General Approach 
The fraction of patients who undergo the EGD and detailed mapping along with confocal laser 
microscopy and have signet ring foci identified will be reported. 
8.4.1 Analysis of the Primary Endpoints 
The fraction of patients who undergo the EGD and detailed mapping along with confocal 
endoscopic microscopy and have signet ring cell foci identified will be reported along with 80% 
and 95% two-sided confidence intervals. 
8.4.2 Analysis of the Secondary Endpoint(s) 
In those patients who choose to undergo prophylactic total gastrectomy with permanent 
pathologic analysis, the false negative rate, that is, the fraction of patients who have SRC foci 

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which were not identified by CEM, will be determined and reported along with 80% and 95% 
two-sided confidence intervals. 
9 
HUMAN SUBJECTS PROTECTIONS  
9.1 
RATIONALE FOR SUBJECT SELECTION 
Subjects from all racial/ethnic groups are eligible for this study if they meet the eligibility 
criteria. Efforts will be made to extend accrual to a representative population. 
9.2 
PARTICIPATION OF CHILDREN 
Children are excluded from this study because endoscopic screening for CDH1 mutation carriers 
is not recommended in children.  
9.3 
PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT 
Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (Section 9.5), all subjects will be offered the opportunity to fill in their 
wishes for research and care, and assign a substitute decision maker on the “NIH Advance 
Directive for Health Care and Medical Research Participation” form so that another person can 
make decisions about their medical care in the event that they become incapacitated or 
cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH 
Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate. For those subjects that become incapacitated and do not have 
pre-determined substitute decision maker, the procedures described in NIH HRPP SOP 14E for 
appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and 
(b) who do not have a legal guardian or durable power of attorney, will be followed. 
9.4 
PARTICIPATION OF PREGNANT WOMEN 
Pregnant women with CDH1 germline mutations are at the same risk for developing gastric 
cancer than non-pregnant women. For this reason and because there is a prospect of direct 
benefit from research participation (Section 9.5.3) pregnant women will be included in this 
study.  In addition, some women who are pregnant may require endoscopic screening depending 
on the timing of diagnosis or the presence of gastrointestinal symptoms. If an endoscopy is 
indicated, and the patient wishes to be enrolled, there is no reason that they should be excluded 
from the protocol. Women undergo invasive abdominal and thoracic surgery if needed during 
pregnancy.  Pregnant women will not receive the intravenous contrast agent, fluorescein, if they 
are enrolled. 
9.5 
EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS 
These evaluations apply to all participants. All care will be taken to minimize side effects, but 
they can be unpredictable in nature and severity. This study may involve risks to patients, which 
are currently unforeseeable. 

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9.5.1 Risks for All Participants Including Subjects Unable to Consent 
Risks of Upper Endoscopy 
The risks of upper endoscopy include, but are not limited to, temporary throat soreness, 
gastrointestinal bleeding, and rarely gastrointestinal perforation. 
Risks of Fluorescein Intravenous Administration 
The risks of intravenous administration of the contrast agent fluorescein are: nausea, vomiting, 
dizziness, headache, and low blood pressure. 
Risks of General Anesthesia 
The risks of general anesthesia include, but are not limited to, temporary confusion and memory 
loss, dizziness, difficulty passing urine, bruising or soreness from the IV drip, nausea and 
vomiting, shivering and feeling cold, sore throat, heart attack, pneumonia and stroke. 
Risk of Biopsies  
All care will be taken to minimize risks that may be incurred by tumor sampling. Biopsies will 
be taken during endoscopy. All procedure-related risks (such as bleeding, infection and visceral 
injury) will be explained fully during informed consent. 
9.5.2 Benefits for All Participants Including Subjects Unable to Consent 
The benefit is detection of gastric cancer at its earliest stage so that it is potentially curable. 
9.5.3 Risk/Benefit Analysis for Pregnant Women 
The benefit is detection of gastric cancer at its earliest stage so that it is potentially curable. We 
will be following the anesthesia guidelines for pregnant women, i.e., waiting until the second 
trimester. All described risks described in Section 9.5.1 apply for pregnant women and there are 
also additional risks, including fetal loss, premature labor, and delivery. 
9.6 
CONSENT PROCESS AND DOCUMENTATION 
The investigational nature and research objectives of this trial, the procedures and treatments 
involved and their attendant risks and discomforts and benefits, and potential alternative 
therapies will be carefully explained to the patient, and a signed informed consent document will 
be obtained by a study investigator prior to entry onto the study. 
The PI or associate investigator will meet with the patient to discuss the protocol treatment and 
alternative options in detail. It will be stated clearly that participation in the research study is 
voluntary and that participants can withdraw from the study without losing benefits they would 
otherwise be entitled to. The patient will be encouraged to ask questions, and additional meetings 
to discuss the treatment options will be arranged as necessary. 
9.6.1 Telephone Consent 
The informed consent document will be sent to the subject. An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form. 
The subject will sign and date the informed consent. The original informed consent document 

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will be sent back to the consenting investigator who will sign and date the consent form with the 
date the consent was obtained via telephone.  
A fully executed copy will be returned via mail for the subject’s records. 
The informed consent process will be documented in the medical record. 
10 DEVICE INFORMATION 
There will be no IDE obtained for the use of Cellvizio® 100 Series systems with Confocal 
Miniprobes™ and Olympus GIF 180 endoscope in this study.  
The devices used on this study, the Cellvizio® 100 Series systems with Confocal Miniprobes™ 
and Olympus GIF 180 endoscope, meet the requirements for exemption under 21 CFR 
812.2.C.2, “A device, other than a transitional device, introduced into commercial distribution on 
or after May 28, 1976, that FDA has determined to be substantially equivalent to a device in 
commercial distribution immediately before May 28, 1976, and that is used or investigated in 
accordance with the indications in the labeling FDA reviewed under subpart E of part 807 in 
determining substantial equivalence.”  
10.1 SOURCE  
Cellvizio® 100 Series systems with Confocal Miniprobes™ will be purchased from Mauna Kea 
Technologies and Olympus GIF 180 endoscope will be purchased from Global Endoscopy 
Solutions. 

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11 REFERENCES 
1. 
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3. 
Oliveira, C., et al., Familial gastric cancer: genetic susceptibility, pathology, and 
implications for management. Lancet Oncol, 2015. 16(2): p. e60-70. 
4. 
van der Post, R.S., et al., Hereditary diffuse gastric cancer: updated clinical guidelines 
with an emphasis on germline CDH1 mutation carriers. J Med Genet, 2015. 52(6): p. 
361-74. 
5. 
Pecina-Slaus, N., Tumor suppressor gene E-cadherin and its role in normal and 
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Colvin, H., et al., Hereditary Gastric Cancer Syndromes. Surg Oncol Clin N Am, 2015. 
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Moreira, L. and A. Castells, Surveillance of patients with hereditary gastrointestinal 
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8. 
Fitzgerald, R.C., et al., Hereditary diffuse gastric cancer: updated consensus guidelines 
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436-44. 
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Huntsman, D.G., et al., Early gastric cancer in young, asymptomatic carriers of germ-
line E-cadherin mutations. N Engl J Med, 2001. 344(25): p. 1904-9. 
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Syngal, S., et al., ACG clinical guideline: Genetic testing and management of hereditary 
gastrointestinal cancer syndromes. Am J Gastroenterol, 2015. 110(2): p. 223-62; quiz 
263. 
11. 
van der Post, R.S., et al., Accuracy of Hereditary Diffuse Gastric Cancer Testing Criteria 
and Outcomes in Patients With a Germline Mutation in CDH1. Gastroenterology, 2015. 
149(4): p. 897-906 e19. 
12. 
Yao, K., The endoscopic diagnosis of early gastric cancer. Ann Gastroenterol, 2013. 
26(1): p. 11-22. 
13. 
Hebbard, P.C., et al., Prophylactic total gastrectomy (PTG) for hereditary diffuse gastric 
cancer (HDGC): the Newfoundland experience with 23 patients. Ann Surg Oncol, 2009. 
16(7): p. 1890-5. 
14. 
Dunbar, K.B. and M.I. Canto, Confocal laser endomicroscopy in Barrett's esophagus and 
endoscopically inapparent Barrett's neoplasia: a prospective, randomized, double-blind, 
controlled, crossover trial. Gastrointest Endosc, 2010. 72(3): p. 668. 
15. 
Kakeji, Y., et al., Development and assessment of morphologic criteria for diagnosing 
gastric cancer using confocal endomicroscopy: an ex vivo and in vivo study. Endoscopy, 
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16. 
Kitabatake, S., et al., Confocal endomicroscopy for the diagnosis of gastric cancer in 
vivo. Endoscopy, 2006. 38(11): p. 1110-4. 
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Carneiro, F., et al., Model of the early development of diffuse gastric cancer in E-
cadherin mutation carriers and its implications for patient screening. J Pathol, 2004. 
203(2): p. 681-7. 
18. 
Corso, G., et al., Characterization of the P373L E-cadherin germline missense mutation 
and implication for clinical management. Eur J Surg Oncol, 2007. 33(9): p. 1061-7. 
19. 
Grady, W.M., et al., Methylation of the CDH1 promoter as the second genetic hit in 
hereditary diffuse gastric cancer. Nat Genet, 2000. 26(1): p. 16-7. 
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Oliveira, C., et al., Intragenic deletion of CDH1 as the inactivating mechanism of the 
wild-type allele in an HDGC tumour. Oncogene, 2004. 23(12): p. 2236-40. 
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Oliveira, C., et al., Quantification of epigenetic and genetic 2nd hits in CDH1 during 
hereditary diffuse gastric cancer syndrome progression. Gastroenterology, 2009. 136(7): 
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Humar, B., et al., Destabilized adhesion in the gastric proliferative zone and c-Src kinase 
activation mark the development of early diffuse gastric cancer. Cancer Res, 2007. 67(6): 
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Karni, R., et al., Active Src elevates the expression of beta-catenin by enhancement of 
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Cancer Genome Atlas Research, N., Comprehensive molecular characterization of 
gastric adenocarcinoma. Nature, 2014. 513(7517): p. 202-9. 
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Kakiuchi, M., et al., Recurrent gain-of-function mutations of RHOA in diffuse-type 
gastric carcinoma. Nat Genet, 2014. 46(6): p. 583-7. 

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12 APPENDICES 
12.1 APPENDIX A: CLINICAL CRITERIA FOR GENETIC TESTING DUE TO A HISTORY 
SUGGESTIVE OF HEREDITARY DIFFUSE GASTRIC CANCER (HDGC) SYNDROME 
Criteria 
Definition 
1 
Family with 2 or more cases of GC regardless of age, with at least one confirmed DGC 
2 
One case of DGC at age < 40 years 
3 
Personal or family history of both DGC and LBC, with one diagnosed at age < 50 years 
Expanded criteria 
 
Bilateral LBC or family history of 2 or more cases of LBC at age < 50 years 
 
A personal or family history of cleft lip/palate in a patient with DGC 
 
In situ signet ring cells and/or pagetoid spread of signet ring cells on stomach biopsy 
GC, gastric cancer; DGC, diffuse gastric cancer; LBC, lobular breast cancer