EBUS-Miniforceps Biopsy Specimen Acquisition for PD-L1 Testing in Nonsmall Cell Lung Cancer: A Feasibility Study
Phase: NA
Conditions: Non Small Cell Lung Cancer, NSCLC
Sponsor: Washington University School of Medicine

Title: 
EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in 
nonsmall cell lung cancer:  A feasibility study 
 
NCT: 
 
NCT04159025 
 
Version Date:   
05/26/2021 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
1 
 
EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A 
feasibility study 
 
 
Protocol Date: 9/20/2018 
 
Version 2 Date: 05/26/21 
 
Principle Investigator:  Alexander Chen, M.D. 
Contact information: 
Alexander Chen, M.D. 
Associate Professor of Medicine 
Washington University School of Medicine 
Phone: 314-454-8764 
Fax: 314-454-5571 
Email: chenac@wustl.edu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
2 
 
 
 
OBJECTIVES 
The objective of this study is to assess the feasibility of utilizing endobronchial ultrasound guided 
miniforceps to acquire adequate amounts of tissue to perform PD-L1 testing on in patients with 
nonsmall cell lung cancer.  Adequacy will be defined as sufficient core biopsy material to perform the 
PD-L1 assay specific for nivolumab. 
SPECIFIC AIMS: 
To evaluate the technique of EBUS-MFB in obtaining adequate tissue to perform PD-L1 testing. 
I. BACKGROUND 
Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has significantly 
changed the landscape for the diagnosis and staging of lung cancer and intrathoracic malignancy.  
Previously, patients with suspected lung cancer required invasive surgical techniques to adequately 
stage disease prior to therapy.  Presently, EBUS-TBNA is recommended by the American College of Chest 
Physicians for the diagnosis of suspected lung cancer based on the body of literature supporting the 
efficacy of this technique as well as its favorable safety profile compared to more invasive surgical 
techniques such as mediastinoscopy or thoracoscopy (Silvestri GA et al. Chest 2013;143:e211S-e250S). 
The development of molecular profiling for lung cancer has significantly altered the treatment for this 
disease (NCCN Task Force Report. JNCCN 2011;9(5)).  The discovery of molecular mutations such as the 
epidermal growth factor receptor (EGFR) have allowed targeted therapy to be given to patients with 
certain molecular profiles, improving quality of life as well as periods of disease free progression for 
certain patients with advanced stages of lung cancer.   
Immune checkpoint inhibition targeting PD-L1 is therapy for patients with advanced nonsmall cell lung 
cancer that has become standard of care.  Currently, the assay for detection of PD-L1 has only been 
approved for use with core biopsy specimens, and not cytologic, needle based preparations.  As EBUS-
TBNA is recommended as a first line procedure over surgical techniques, many patients undergoing this 
staging procedure will not have tissue specimens which are adequate for PD-L1 testing, and may require 
additional procedures to obtain core material for PD-L1 testing. 
Recently, new instrumentation has become available for endobronchial ultrasound which propose to 
provide core biopsy specimens using this bronchoscopic approach.  Endobronchial ultrasound guided 
miniforceps biopsies (EBUS-MFB) have been safely used to obtain larger amounts of tissue than 
traditionally provided by transbronchial needle aspiration.  In this technique, small, 1mm forceps are 
placed through the working channel of the EBUS bronchoscope and are passed directly into mediastinal 
lymph nodes or centrally located mediastinal or hilar lesions and are used to obtain “core” biopsies of 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
3 
targeted areas.  EBUS-MFB has shown efficacy and safety for the diagnosis of granulomatous 
inflammation and lung cancer (Chen A, et al. Ann Thorac Surg 2011;92:284-289), though has not been 
specifically evaluated for the use of collecting material for PD-L1 testing, which is relatively new. 
RATIONALE:   
The incorporation of PD-L1 testing into clinical practice has progressed at a rapid pace, and now offers 
an additional line of therapy for eligible patients with nonsmall cell lung cancer.  The assay used to 
detect circulating levels of PD-L1 currently requires core biopsies, and is not approved to be used for 
specimens collected through a needle based cytological technique.  Though EBUS-TBNA has markedly 
improved the manner in which patients are diagnosed and staged for lung cancer, alternative means of 
tissue collection may be mandatory to offer patients access to newer lines of therapy such as PD-L1 
inhibition.  EBUS-miniforceps biopsy may allow bronchoscopists to obtain core biopsy specimens 
through the technique of endobronchial ultrasound, so that more invasive approaches such as surgery 
may be avoided.  Feasibility using this approach would indicate that all patients being staged with 
endobronchial ultrasound procedures would be candidates for PD-L1 testing and potential therapy. 
This study is proposed to evaluate the feasibility of using EBUS-MFB to acquire tissue that is adequate 
for PD-L1 testing. Feasibility in this study is defined as the ability to obtain adequate material during 
EBUS procedures to perform PD-L1 testing.  
II. RESEARCH DESIGN AND METHODS 
This is a single center prospective feasibility study to assess the adequacy of specimens collected using 
EBUS-miniforceps for performing PD-L1 testing using the nivolomab assay. 
The patient population in this study is patients with advanced stage lung cancer.  The protocol outlines 
our standard of care approach, which is to perform a full staging EBUS examination of the mediastinum 
and hila, starting with N3 nodes, then moving to N2 nodes and finally to N1 nodes as needed.  Rapid on-
site evaluation (ROSE) is utilized to give on-site feedback to the bronchoscopist so that we know if the 
lymph node being sampled is diagnostic on-site.  If, for example, an N3 lymph node is diagnostic, then 
we do not need to subject the patient to additional procedural or anesthesia related risks of sampling 
additional lymph nodes.  The information provided from the original lymph node is diagnostic and 
pathologically stages the patient.  This is standard of care. 
Primary outcomes: Adequacy of collected material to perform PD-L1 testing on specimens collected 
using EBUS-MFB using the nivolomab assay. 
Secondary outcomes: 
1. Adverse event rates and safety profile of EBUS-MFB. 
DEFINITIONS:  

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
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Central lung lesion: lesions immediately adjacent to the tracheobronchial tree accessible by biopsy using 
convex-probe endobronchial ultrasound and inclusive of, but not limited to, mediastinal and hilar 
lymphadenopathy. 
Feasibility: feasibility will be defined as the ability to provide adequate specimens to perform PD-L1 
testing.  Any specimen in which the requested assay returns as “insufficient material to perform testing” 
will be deemed an “inadequate” specimen. 
SUBJECT ENROLLMENT: 
Subjects presenting to the Interventional Pulmonology service at Washington University School of 
Medicine in need of a bronchoscopic biopsy of their central lung lesion as part of their standard medical 
care, and who meet study inclusion/exclusion criteria, will be invited to participate.  A total of 20 
patients will be enrolled in this feasibility study.  The PI will explain the study to qualified subjects prior 
to obtaining consent. The subject will also be given an opportunity to review and sign documentation of 
HIPAA compliance and authorization.  
 
Inclusion criteria: 
Patients to be included for participation in this study are: 
1. Patients with central lung lesion 1cm in size or larger identified on chest CT with the intention to 
undergo bronchoscopic evaluation and biopsy.  The decision to pursue biopsy will be made by 
the treating physician and agreed upon by the patient.   
2. Are at least 18 years old 
3. Are able to provide informed consent 
4. Are not pregnant as confirmed by bHCG testing prior to procedure 
 
Exclusion criteria: 
Patients to be excluded from participation in this study are: 
1. Patients who refuse to participate 
2. Are less than 18 years of age 
3. Are pregnant 
4. Are physically unable to tolerate flexible bronchoscopy or moderate sedation as determined by 
the bronchoscopist 
5. Are unable to provide informed consent 
6. Are on anticoagulant medications and who cannot safely discontinue their medication prior to 
their procedure at the recommendation of their treating physician 
 
 
INFORMED CONSENT: 
 
Informed consent will take place in a private environment (e.g. patient exam room), free from 
distractions. The PI (or another member of the study team with consenting duty) will approach the 
subject at their standard of care clinic appointment or prior to their scheduled bronchoscopy and will 
explain the study to qualified subjects prior to obtaining consent. Interviews to obtain consent will not 
follow any stressful situation (e.g. patient being informed he/she may have cancer) and will not be 
conducted if patient has received any mind-altering medications or anesthesia. Patients will be assessed 
for their capacity to consent by the ability to show comprehension of the procedure, ask appropriate 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
5 
questions, and appear properly oriented. A signed copy of all consents and the HIPAA authorization 
document will also be given to consenting subjects. 
 
PROCEDURES: 
All procedures will be performed in an outpatient bronchoscopy suite.  All procedures will be performed 
under moderate sedation. 
Bronchoscopy:  
1. Sedation: Moderate sedation will be administered by the bronchoscopy team in a dedicated 
bronchoscopy suite.  Patients will be continuously monitored throughout the procedure as per 
standards of care at Barnes-Jewish Hospital. 
2. Airway inspection: When adequate sedation has been given, the bronchoscope (BF-P190, 
Olympus, Tokyo, Japan) will be inserted transorally into the tracheobronchial tree and a 
standard airway inspection will be performed. 
3. Convex-probe endobronchial ultrasound and transbronchial needle aspiration: Following 
standard airway inspection, the convex-probe EBUS bronchoscope (BF-UC180F, Olympus, Tokyo, 
Japan) will be inserted transorally into the tracheobronchial tree and will be advanced to the 
targeted centrally located lesion.  Transbronchial needle aspiration from the targeted lesion will 
be performed using a 22 gauge aspiration needle. 
4. Rapid on-site evaluation (ROSE):  Rapid on-site evaluation will be performed as per standard 
clinical care by a cytology team. 
a. ROSE diagnostic: in cases in which ROSE yields a specific diagnosis of nonsmall cell lung 
cancer, EBUS-MFB will subsequently be performed. 
b. ROSE non-diagnostic: in cases in which ROSE does not yield a specific diagnosis, 
additional lymph nodes that are pathologically enlarged as defined above will be 
targeted for EBUS-TBNA 
i. If no additional lymph nodes are pathologically enlarged, the procedure will be 
terminated and EBUS-MFB will not be performed 
5. EBUS-miniforceps biopsy:  following the diagnosis of nonsmall cell lung cancer using ROSE, EBUS-
MFB will be performed in the following manner: 
a. With the EBUS bronchoscope positioned at the targeted lymph node station, 6 needle 
punctures will be made into the targeted lymph node using the 22 gauge aspiration 
needle through the EBUS bronchoscope using continuous endobronchial ultrasound 
guidance.   
b. The 22 gauge aspiration needle will then be removed and 1mm miniforceps (Boston 
Scientific), will be passed through the working channel of the EBUS-bronchoscope into 
the targeted lymph node through the puncture site made using the 22 gauge needle 
using continuous endobronchial ultrasound guidance. 
c. The miniforceps will be used to obtain a core biopsy of the targeted lymph node using 
continuous endobronchial ultrasound guidance and will be withdrawn from the EBUS 
bronchoscope. 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
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d. 8 core biopsies will be obtained from each targeted lymph node using this technique, 
with each core biopsy specimen placed in formalin for PD-L1 testing. 
6. Management of complications: the major complications of bronchoscopic biopsy include 
pneumothorax and bleeding: 
a. Pneumothorax: a post procedure chest x ray will be performed following the 
bronchoscopy.  Should a pneumothorax be present, it will be managed by either 
observation and follow up chest x-ray or by tube thoracostomy at the discretion of the 
bronchoscopist. 
b. Bleeding: intra procedural bleeding will be managed using local tamponade, iced saline 
lavage or mechanical occlusion at the discretion of the bronchoscopist. 
Post-bronchoscopy:  
1. Chest x-ray: A routine portable chest x-ray will be performed on all patients following 
bronchoscopy as per standard clinical practice at Barnes-Jewish Hospital/Washington University 
School of Medicine to assess for pneumothorax.  
2. Recovery: Patients will be recovered in a dedicated post-procedure area as per standard care at 
Barnes-Jewish Hospital/Washington University School of Medicine 
Laboratory Analysis: 
1. Formalin placed specimens will be sent for PD-L1 testing using the assay specific for nivolumab. 
 
RISKS OF PROCEDURES: 
 
The greatest risks from bronchoscopy are related to moderate or deep sedation and the very act of 
passing a bronchoscope into the airway.  To mitigate risks of bronchoscopy all patients will be 
monitored by a nurse and a respiratory therapist during the procedure. In addition, oxygen saturation 
(using pulse oximetry) respiratory rate, blood pressure, ECG, and heart rate will be continuously 
monitored.  Patients will not be released until they are fully awake and medically stable. 
  
The risks associated with bronchoscopy are collapsed lung, breathing difficulty, vocal cord spasm, 
vomiting, dizziness, bronchial spasm, infection, low blood oxygen, heart attack and bleeding from 
biopsied site. The occurrence of these risks is extremely low.  The measures to mitigate the risks are the 
same as for all bronchoscopy. To assess for pneumothorax following the bronchoscopy, patients will get 
a portable chest X-ray. To minimize the chance of bleeding, all patients will be questioned about 
tendency to bleed prior to bronchoscopy as per standard care. Anticoagulation with antiplatelet agents 
will be held according to guideline recommendations for that drug. If bleeding occurs, patients will be 
treated with direct pressure, local instillation of epinephrine or electrocautery. Patients with lung 
disease may receive bronchodilators prior to bronchoscopy at the discretion of the performing 
bronchoscopist. There is no way to reduce the minimal risk of infection due to bronchoscopy since the 
scope must go through the oropharynx. Patients are given supplemental oxygen and their oxygen level is 
continuously monitored using pulse oximetry. Patients ECG, heart rate, blood pressure, and blood 
oxygen are continuously monitored by a nurse, respiratory therapist and physician during the 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
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procedure. If there is any sign of a worsening in status, such as elevated heart rate, low oxygen, or ECG 
changes, the procedure will be aborted.  
 
RESEARCH ONLY RISKS: 
 
Risk of breach in confidentiality 
Every effort will be made to protect the privacy of the research subjects.  All information and data 
related to this study will be maintained in secured, protected space, and access will be restricted to 
study personnel only. 
 
DATA COLLECTION 
(1) Feasibility: feasibility will be determined as the ability to provide adequate specimens to 
perform PD-L1 testing.  Any specimen in which the requested assay returns as “insufficient 
material to perform testing” will be deemed an “inadequate” specimen.  Adequacy for PD-L1 
testing will be recorded. 
(2) Radiographic Information: Size and location of the central pulmonary lesion will be recorded.  
Size will be recorded as the longest axis diameter.   
(3) Procedural Characteristics: Procedural information to be recorded will include procedure time, 
amount of sedation given, and number of biopsies performed 
(4) Diagnostic yield: Diagnostic yield based on final cytology and/or histopathology will be 
determined from the results of the bronchoscopy.  A biopsy that results in a specific diagnosis, 
either malignant or benign, that adequately explains the clinical scenario as determined by the 
treating physician, will be considered truly positive.  Plan for further diagnostic management for 
patients who have a non-diagnostic procedure will be determined by the treating physician as 
clinical indicated. 
(5) Complications: Adverse event rates will be documented. Pneumothorax will be documented by 
post-biopsy CXR or chest ultrasonography, and the number requiring intervention, such as chest 
tube placement, will be recorded. Significant hemoptysis will be defined as bleeding noted at 
the time of procedure that requires a change in the level of care (e.g. outpatient to inpatient or 
inpatient to ICU) or a blood transfusion.  Other adverse events that are common to 
bronchoscopy described above in “Risks” section will be monitored and reported by the patient 
or nursing staff. 
DATA SAFETY MONITORING PLAN 
 
All subjects enrolled in the trial will undergo routine standard of care bronchoscopy that is indicated as 
medically necessary by their physicians. Prior to the bronchoscopic procedure, PI will explain the risks 
associated with bronchoscopy, and verify that the research only risks have been explained, and that the 
subject has signed an informed consent form. There are no anticipated risks, outside of the risk for the 
standard of care procedures for this clinical trial. All subjects are required to read, understand, and sign 
the informed consent form associated with the research study. Each subject will be informed of post 
procedure symptoms of which to be aware that may represent adverse reactions to the bronchoscopy.  
Symptoms that the patient will be informed to look out for include: 
• 
Pain or difficulty with swallowing 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
8 
• 
Difficulty breathing 
• 
Vomiting 
• 
Dizziness 
• 
Abdominal or chest pain 
• 
Continuous bright red blood in your sputum 
• 
Fever above 100.0 degrees Fahrenheit 
If the subject notes any of these symptoms, he/she is instructed to contact his/her physician, who will 
determine the course of action. All adverse events (AEs) will be reviewed by the medical monitor within 
one month of their occurrence and summarized for review.  The PI will be responsible for submitting this 
report to the IRB at his/her institution as required. AEs and other reportable events are defined below. 
 
Reportable Events 
(1) AEs 
AEs will be defined as any untoward or unfavorable medical occurrence in a human subject, including 
any abnormal sign, symptom, or disease, temporally associated with the subject's participation in the 
research, whether or not considered related to the subject's participation in the research. Regarding AEs 
and SAEs, “temporally” will be defined as occurring within 24 hours post-procedure.  Serious Adverse 
Events (SAEs) will be defined as any adverse event temporally associated with the subject's participation 
in research that meets any of the following criteria: 
* results in death; 
* is life-threatening; 
* requires inpatient hospitalization or prolongation of existing hospitalization; 
* results in a persistent or significant disability/incapacity; 
* results in a congenital anomaly/birth defect; or 
* any other adverse event that, based upon appropriate medical judgment,    
  may jeopardize the subject's health and may require medical or surgical  
  intervention to prevent one of the other outcomes listed in this definition. 
If the subject notes any of these symptoms, he/she is instructed to contact his/her physician, who will 
determine the course of action. PI will be responsible for identifying adverse events during the 
procedure and during the standard of care follow-up period. Site PIs will review adverse events 
experienced by subjects treated at their site during the procedure standard of care follow-up period and 
will record them in the medical record. The study team will review the participant’s medical record up to 
24 hours after the procedure to monitor if adverse events have occurred. The PI will review all adverse 
events, expected or unexpected, per standard medical care. PI will classify AEs as expected or 
unexpected, and report AEs directly to the IRB per WU IRB reporting policy.  
 
Unanticipated problems and noncompliance events will be reported to the WU IRB according to IRB 
definition and reporting timeframes. Study participants will be followed for 24 hours post-procedure for 
AEs.   
 
In compliance with the Washington University Institutional Data and Safety Monitoring Plan, the 
Principal Investigator will provide a Data and Safety Monitoring (DSM) report to the Washington 
University Quality Assurance and Safety Monitoring Committee (QASMC) semi-annually beginning six 
months after accrual has opened (if at least five patients have been enrolled) or one year after accrual 
has opened (if fewer than five patients have been enrolled at the six-month mark). 
 
DATA STORAGE AND MAINTENANCE: 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
9 
The PI will review the results, and the results will become part of the subject’s medical record and 
research record. Any clinical follow-up or repeat procedures will be dictated by the patient’s physician 
based on clinically relevant data and will not be influenced by enrollment into this study. To protect 
subject confidentiality, all patient health information will be de-identified through use of 6 digit patient 
codes. All information and data related to this study will be stored in a secured, locked cabinet in the 
PI’s office which is only accessible by the PI.  Electronic data will be stored on the PI’s password 
protected computer located in the PI’s locked office. Study participants will be added to Oncore within 1 
day of being enrolled into the study.  
 
REGISTRATION PROCEDURES: 
Patients must not start any protocol intervention prior to registration through the Siteman Cancer 
Center. 
The following steps must be taken before registering patients to this study: 
1. Confirmation of patient eligibility 
2. Registration of patient in the Siteman Cancer Center OnCore database 
3. Assignment of unique patient number (UPN) 
  
Confirmation of Patient Eligibility 
Confirm patient eligibility by collecting the information listed below: 
1. Registering MD’s name 
2. Patient’s race, sex, and DOB 
3. Three letters (or two letters and a dash) for the patient’s initials 
4. Copy of signed consent form 
5. Completed eligibility checklist, signed and dated by a member of the study team 
6. Copy of appropriate source documentation confirming patient eligibility 
  
Patient Registration in the Siteman Cancer Center OnCore Database 
All patients must be registered through the Siteman Cancer Center OnCore database at Washington 
University. 
 
STATISTICAL ANALYSIS 
 
The primary objective of this study is to determine the success rate of performing PD-L1 testing using 
the nivolumab specific assay on specimens collected using an EBUS-miniforceps core biopsy technique.  
This is a feasibility study with a target enrollment of 20 patients. 
Descriptive statistics will be calculated to characterize study subjects and procedure, which include the 
mean±SD for continuous variables and percentages for categorical variables, such as subject’s age at 
procedure performed, race, gender, the number of biopsy passes, location of lymph node, the time 
length of procedure, type and amount of sedation administered, and adverse events. 
 
 
 

Washington University School of Medicine 
PI: Alexander Chen, M.D. 
Title: EBUS-Miniforceps biopsy specimen acquisition for PD-L1 testing in nonsmall cell lung cancer: A feasibility study 
 
Version 2, 5/26/21, to incorporate revisions from 3/2021 QASMC audit  
10