2D and 4D Contrast-enhanced Ultrasound Evaluation of Hepatocellular Carcinoma Chemoembolization
Phase: PHASE3
Conditions: Hepatocellular Carcinoma, Chemoembolization, Therapeutic
Sponsor: Sidney Kimmel Comprehensive Cancer Center at Thomas Jefferson University

PROTOCOL 
 
TITLE:  2D AND 4D CONTRAST-ENHANCED ULTRASOUND EVALUATION OF 
HEPATOCELLULAR CARCINOMA CHEMOEMBOLIZATION 
 
VERSION & DATE:  Version 6.1 – August 1, 2019 
 
PRINCIPAL INVESTIGATOR:  
John Eisenbrey, PhD 
Research Assistant Professor  
Department of Radiology 
Thomas Jefferson University  
132 South 10th Street, 7th Floor 
Philadelphia, PA 19107 
Email address: john.eisenbrey@jefferson.edu 
Tel: 215-503-5188 
Fax: 215-955-8549 
KEY PERSONNEL: 
Colette Shaw, MD 
 
 
 
Flemming Forsberg, PhD 
Assistant Professor 
 
 
 
Professor 
 
 
Department of Radiology 
 
 
Department of Radiology 
Thomas Jefferson University 
 
 
Thomas Jefferson University 
 
Patrick O’Kane, MD 
 
 
 
Laurence Parker, PhD 
Assistant Professor  
 
 
 
Professor 
Department of Radiology 
 
 
Department of Radiology 
Thomas Jefferson University 
 
 
Thomas Jefferson University 
 
Andrej Lyshchik, MD, PhD 
 
 
Jesse Civan, MD 
Assistant Professor 
 
 
 
Assistant Professor 
Department of Radiology 
 
 
Department of Hepatology 
Thomas Jefferson University 
 
 
Thomas Jefferson University 
 
Allison Tan, MD 
 
 
 
Amanda Smolock, MD 
Assistant Professor 
 
 
 
Assistant Professor 
Department of Radiology 
 
 
Department of Radiology 
Thomas Jefferson University 
 
 
Thomas Jefferson University 
 
 
 
 
Yuko Kono, MD, PhD  
 
 
Robert Mattrey, MD 
 
Associate Professor  
 
 
 
Professor Emeritus 
Departments of Medicine and Radiology 
Department of Radiology 
University of California, San Diego 
 
University of Texas, Southwestern 
 
Steve Rose, MD 
 
 
 
Michael Soulen, MD 
Professor 
 
 
 
 
Professor  
Department of Radiology 
 
 
Department of Radiology 
University of California, San Diego 
 
Hospital of the University of Pennsylvania 
 
Arthur Fleischer, MD 
Professor 
Department of Radiology 
Vanderbilt University Medical Center 

 
2
 
 
Medical Monitor: 
Robert Den, MD 
 
 
 
 
 
Research Coordinators:  
 
 
 
Nancy Pedano, Thomas Jefferson University 
  
 Avery Huberts, University of California, San Diego 
 
 T.B.N., University of Pennsylvania 
 
 
 
 
Sonographers: 
Corrine Wessner, RDMS, Thomas Jefferson University 
Susan Schultz, RDMS, University of Pennsylvania 
 
Research Nurses: 
Cynthia Miller, RN, Thomas Jefferson University 
Kristen Bradigan, RN, Thomas Jefferson University 
LOCATIONS OF STUDY:   
Thomas Jefferson University 
 
 
132 South 10th Street, 7th Floor  
 
Philadelphia, PA  19107 
 
University of California, San Diego 
9500 Gilman Drive 
La Jolla, CA 92093 
 
Hospital of the University of Pennsylvania 
3400 Spruce St. 
Philadelphia, PA 19104 
 
 
 
STUDY DURATION:  5 year project (January 2016-December 2020) 
 
 
 
CONFIDENTIALITY STATEMENT: 
This document is the confidential property of Thomas Jefferson University.  No part of it may be 
transmitted, reproduced, published, or used by other persons without the permission of Thomas Jefferson 
University. 
 
 
 
 
 
 
 

 
3
 
 
 
TABLE OF CONTENTS 
PAGE 
SYNOPSIS  ..................................................................................................................... 4 
 
1. INTRODUCTION  ................................................................................................... 8 
1.1  Background  ............................................................................................................. 9 
1.2  Rationale  .................................................................................................................. 15 
 
2. TRIAL OBJECTIVES  ............................................................................................. 15 
 
3 
TRIAL DESIGN  ...................................................................................................... 15 
3.1  Trial Duration  .......................................................................................................... 16 
 
4. TRIAL POPULATION  ........................................................................................... 16 
4.1  Inclusion Criteria  .................................................................................................... 16 
4.2  Exclusion Criteria  .................................................................................................... 16 
 
5. MEDICATIONS  ..................................................................................................... 17 
5.1 Contraindications  ..................................................................................................... 17 
5.2 Randomization  ......................................................................................................... 17 
5.3 Blinding and Unblinding Methods  .......................................................................... 18 
5.4 Storage  ..................................................................................................................... 18 
 
6. TRIAL PROCEDURES  .......................................................................................... 18 
6.1  Patient Enrollment  ................................................................................................... 18 
6.2  Screening Assessment  ............................................................................................. 18 
6.3  Ultrasound Imaging  ................................................................................................. 19 
6.4  Safety Monitoring  .................................................................................................... 20 
6.5  Efficacy Assessments  .............................................................................................. 20 
6.6  Safety Assessments  ................................................................................................. 21 
 6.6.1 Unanticipated Problems  ..................................................................................... 21 
 6.6.2 Adverse Events  .................................................................................................. 21 
 6.6.3 Serious Adverse Events....................................................................................... 21 
 6.6.4 Safety Assessment and Follow Up ...................................................................... 22 
 6.6.5 Recording of Adverse Events .............................................................................. 22 
 6.6.6 Safety Reporting ................................................................................................. 23 
6.7  End-of-Treatment and End-of-Trial Evaluations  ..................................................... 24 
 6.7.1 Discontinuation of Subjects  ............................................................................... 24 
 
7. DATA MANAGEMENT AND STATISTICAL ANALYSES  ............................... 25 
7.1  Data Management  .................................................................................................... 25 
7.2  Statistical Analyses  .................................................................................................. 25 
 7.2.1 Sample Size Calculation ..................................................................................... 27 
 
8. REFERENCES  ........................................................................................................ 28 
 
Appendix A. Investigator Obligations  
Appendix B. Definity Product Insert 
 
 
 
 
 

 
4
 
 
 
 
 
 
 
SYNOPSIS 
 
Protocol Title: 2D and 4D Contrast-enhanced Ultrasound Evaluation of Hepatocellular Carcinoma 
Chemoembolization 
 
Trial Objectives: The primary objective of this trial is to: 
- 
To evaluate the sensitivity and specificity of 2D and 4D contrast enhanced ultrasound for 
monitoring transarterial chemoembolization (TACE) response 1-2 weeks and 1 month post 
treatment as an alternative to contrast-enhanced magnetic resonance (MRI) or computed 
tomography (CT) imaging 
 
The secondary aim of this trial is to: 
- 
To develop quantitative biomarkers based on the ultrasound contrast agent kinetics for identifying 
patients requiring retreatment of residual disease.   
 
Trial Design:  This is an open-label, non-randomized trial that will be conducted at three clinical sites.  The 
subject population will be patients undergoing transarterial chemoembolization for the treatment of 
hepatocellular carcinoma (HCC) at Thomas Jefferson University, The University of California, San Diego, 
and The Hospital of the University of Pennsylvania. Patients will receive a contrast-enhanced ultrasound 
(CEUS) exam the morning prior to embolization, approximately one week post-embolization, and at their 
one month MRI follow up (scheduled as part of their clinical standard of care).  
 
Trial Population: This trial will consist of up to 210 adults (with a maximum of up to 100 at any institution) 
undergoing transarterial chemoembolization for the treatment of HCC split between Thomas Jefferson 
University, The University of California, San Diego, and The Hospital of the University of Pennsylvania.  
 
Trial Procedures: Patients will be identified and consecutively approached from each institution’s 
Hepatology / Transplant Surgery and Interventional Radiology practices (by each site’s Hepatology or 
Interventional Radiology co-investigators). An investigator or research coordinator will explain the study 
to the patient. The patient will be given time to consider the risks and benefits of the study and to ask 
questions about participation. A consent form will be reviewed with the patient. A full history and physical 

 
5
examination will be obtained from the patient’s referring physician.  If the subject is a woman of 
childbearing potential, she will have a urine pregnancy test prior to each CEUS study (the results of which 
will be made available to the subject prior to study initiation). In the event a patient presents with a lesion 
that is expected to be difficult to view on ultrasound (for example, smaller lesions located high on the liver 
dome), grayscale ultrasound imaging will quickly be performed to ensure the lesion is visible on ultrasound 
and that the patient is suitable for study inclusion. 
 
Patients will undergo a total of three separate CEUS exams. These exams will consist of the baseline study 
prior to TACE therapy, a study 1-2 weeks post treatment that will coincide with clinical post-procedure 
follow-up by the interventional radiologist, and a study approximately one month post treatment when 
patients return for clinically scheduled CE-CT/MRI follow-up. If the patient fails to show up for the 1-2 
week CEUS exam, they will not be excluded from the final ultrasound exam. Procedures and equipment 
for this trial will be used in accordance with standard clinical protocols and good clinical practices already 
in place at our hospitals.  
 
The first three cases at each institution (baseline and at least one follow-up) will be performed under the 
guidance of at least one of the study PIs to ensure standardization amongst all three sites. The ultrasound 
examinations will be performed by a qualified sonographer. Efforts will be made to have all CEUS scans 
performed by the same dedicated sonographer, enabling us to evaluate operator dependence. During the 
ultrasound examination, the patient will be asked to lie in the supine position and a 20-22 gauge cannula 
will be placed in a superficial vein (preferably an antecubital vein). Ultrasound imaging will be performed 
using a state of the art Logiq E9 scanner with C1-5-D broad-spectrum convex transducer and a RAB2-5-D 
broad-spectrum real-time 4D transducer (GE Healthcare, Wauwatosa, WI). As part of this study, we have 
budgeted for the purchase of 3 4D probes (not routinely available in clinical practice) and the installation 
of GE’s ultrasound volumetric and contrast imaging packages that provide 2D and 4D CEUS capabilities. 
In the event the patient has multiple lesions scheduled for treatment, up to 2 lesions will be imaged 
independently on CEUS. Patients will first undergo 2D baseline imaging.  B-mode measurements and 
sweeps of the lesion in the transverse and sagittal planes will be performed, followed by standard power 
Doppler imaging (PDI). Following baseline imaging, patients will receive a bolus IV injection of up to 0.6 
ml of Definity, followed by a 10 cc saline flush. Since Definity is currently only approved for 
echocardiography, we will apply to the FDA for an investigational new drug application for CEUS 
evaluation of TACE (similar to our previous study [Shaw at el. 2014]).  
 
All CEUS imaging will be performed using the dual B-mode (used to locate anatomical features) and 

 
6
nonlinear contrast (to identify the ultrasound contrast agent) imaging mode. A low mechanical index (< 
0.1) will be used to minimize microbubble destruction during imaging. The standard nonlinear imaging 
frequency pairings in the contrast imaging software will be used (transmitting at 2 MHz, receiving at the 4 
MHz harmonic), and gain settings will be adjusted to minimize nonlinear signals prior to contrast injection. 
Additionally, the focal zone will be placed at the approximate depth of the lesion to maximize the generation 
of nonlinear signals during CEUS. During the first contrast injection, 2D CEUS will be performed using 
the coded harmonics nonlinear imaging package on the unit. The approximate tumor mid-line will be 
imaged until homogenous liver enhancement is achieved (approximately 45 seconds post injection), 
followed by imaging sweeps through the tumor. Sweeps will then be acquired in the sagittal plane, before 
returning to the original plane. Imaging will be continued until contrast washout is observed (approximately 
3-4 minutes), after which data will be digitally stored for later review. A ten to  fifteen minute wait period 
will be observed between injections to allow for complete ultrasound contrast agent clearance. A region of 
interest encompassing the entire tumor volume and margin will then be selected in 4D mode.  Baseline 
imaging of the tumor will be repeated in 4D mode in grayscale B-mode. A second bolus injection of up to 
0.6 ml Definity followed by 10 cc saline flush will again be administered during continuous tumor imaging 
in 4D, which uses the machine’s coded harmonics package. Data will be obtained until contrast washout is 
observed and then digitally stored in digital imaging and communications in medicine (DICOM) format for 
later review. 
 
The proposed agent for the current study, Definity is a sterile non-pyrogenic suspension of liposome-
encapsulated perfluoropropane microbubbles [Goldberg et al 2001; Miller & Nanda 2004].  The contrast 
agent is composed of a blend of three phospholipids contained in a matrix of sodium chloride, propylene 
glycol, and glycerin in water.  The contrast agent is supplied in a vial that contains the phospholipids and 
perfluouropropane gas.  The microbubble agent is supplied in a standard-size 2 ml vial and is prepared by 
shaking the vial with the aid of a shaking device (Vialmix: ESPE, Seefeld, Germany).  Definity will be 
stored in a secure cabinet, with only the study investigators and research personnel having access. Definity 
is currently only approved for use in echocardiography.  The agent will be used as an off-label indication 
for this study.  We intend to apply for an FDA investigator-instantiated IND for the off-label usage of 
Definity for the evaluation of chemoembolization using drug eluting beads. 
 
Statistical Methodology: Data analysis from this multi-center clinical trial will be performed to characterize 
2D and 4D CEUS as a follow-up imaging tool for the evaluation of residual tumoral blood flow in patients 
with HCC treated with TACE.  Our statistical analysis will address three major questions:   

 
7
1.  Does 2D and 4D CEUS 1-2 weeks post TACE yield sensitivity and specificity greater than 90%  
for identifying residual tumor blood flow, thereby providing reliable earlier identification (relative 
to the current clinical standard) of patients in need of retreatment? 
2. Does 2D and 4D CEUS 1 month post TACE yield sensitivity and specificity greater than 90% for 
identifying residual tumor blood flow ,thereby providing an accurate, safe, and cost-effective 
imaging alternative for identifying TACE patients in need of retreatment? 
3. Are quantifiable biomarkers generated by parametric imaging of 2D and 4D CEUS exams able to 
differentiate between fully treated and incompletely treated masses by measuring blood flow 
kinetics? 
The first three cases at each institution will be used as reader training cases and will not be included in the 
final analysis. In the event of all cases showing identical response (i.e. all incompletely or completely 
treated), the first case with an alternative outcome will be substituted for the 9th case. Following reader 
training, each reader (all of whom have previous experience with CEUS and volumetric ultrasound) will be 
asked to evaluate all 201 remaining cases. 2D and 4D CEUS exams will be read separately and only after 
randomization. Readers will first be asked to review both the patient’s baseline CE-MRI/CT and CEUS 
exams to identify the size and location of the treated mass. Following baseline review, each reader will 
review the 1-2 week and 1 month CEUS exam (in random order). Intratumoral blood flow will be assessed 
as present or not present. Readers will then be asked to interpret the patient’s 1 month follow-up CE-
MRI/CT images and again evaluate the need to retreat based on residual blood flow. Finally, when 
available, readers will review subsequent CE-MRI/CT imaging studies (up to six months post TACE). 
MRI/CT evaluations will be based on mRECIST criteria.  All imaging studies will be read twice by each 
reader. Studies will be presented in random order. The second round reads will be performed at least one 
month after the first. Outcomes will be defined as incompletely treated (i.e. requiring retreatment) based on 
(in order of preference of reference standard): a) pathological examination of explanted livers 
demonstrating live tumors; b) tumor enhancement seen with CT or MR and confirmed via angiography 
during retreatment; c) tumor growth on 6 month follow-up CE-CT/MRI; or d) asymmetrical or nodular 
tumor enhancement on CE-MRI/CT on 6 month follow-up. Incomplete treatment on CEUS (2D or 4D) will 
be evaluated by each reader and evidenced by the tumor showing either residual blood flow after treatment 
or nodular peripheral blood flow.   
 
For statistical questions 1-2, sensitivity (the ability to detect patients in need of retreatment) and specificity 
(the ability to identify patients who do not require retreatment) will first be calculated on a reader by reader 
basis. Four 2 x 2 tables will be constructed comparing the need for re-treatment based on the clinical gold 
standard and CEUS, tabulating true positives, false positives, false negatives, and true negatives  for CEUS 

 
8
at 1-2 weeks and 1 month for both 2D and 4D CEUS and used to calculate sensitivity, specificity, accuracy, 
positive predictive value, and negative predictive value. Statistical significance between the reference 
standard and each of the 4 CEUS groups will be determined using a McNemar test. These values will also 
be calculated based on the majority decision (i.e. 4 or more readers in agreement). In the event of discordant 
readings during this analysis, tumor outcome will be decided by consensus by the two readers at TJU.  
Differences between techniques (2D vs. 4D) and time points (1-2 weeks vs. 1 month post treatment) will 
be determined by comparing areas under the receiver operating characteristic curves for each modality/time 
point based on necessity of tumor retreatment. Intra-rater and inter-rater variability will be calculated using 
a Shrout and Fleiss Interclass Correlation [Shrout and Fleiss 1979]. Finally, a logistical regression and 
analysis of variance will be performed to determine if significant variations exist between individual sites 
(to determine operator dependence), lesion size (tumor size dependency) or between patients treated with 
cTACE vs. DEB-TACE (treatment dependency). 
 
For statistical question 3, all quantitative parameters will be compared between fully treated and 
incompletely treated masses using a Student’s t-test. Additionally, lesions that demonstrate lack of residual 
enhancement at 1 month, but show recurrence at 6 month follow-up, will be compared to completely treated 
masses to determine if quantitative CEUS parameters can detect this lower level of residual disease. 
Statistical analysis will be performed with assistance from the biostatistician co-investigator using Stata 
12.0 (Stata Corp, College Station, TX) with p values < 0.05 considered statistically significant after a 
Bonferroni-type adjustment for multiple tests. These statistical tests will answer our three major questions 
regarding the sensitivity and specificity of 2D and 4D CEUS as an imaging tool for the follow-up of TACE 
at 1-2 weeks and 1 month, as well as the influence of operator, reader, tumor size, and embolization 
material. 
 
1. INTRODUCTION  
  
Hepatocellular carcinoma (HCC) is the third leading cause of cancer mortality worldwide and the incidence 
is increasing. While surgical resection and transplantation offer the possibility of long-term cure, the 
majority of patients are not eligible for these treatments. Transarterial chemoembolization (TACE) is 
standard of care for patients with Barcelona Clinic Liver Cancer stage B disease but may also be used as 
bridging therapy in patients who are potential transplant candidates. Current guidelines recommend follow-
up imaging 4-6 weeks after all tumor-bearing areas have been treated. Incomplete treatment is defined as 
persistence of enhancing areas inside the treated lesions seen at the first imaging study after locoregional 
treatment and is observed in up to two-thirds of patients post TACE. Contrast-enhanced magnetic resonance 
imaging (CE-MRI) has been established as the clinical standard imaging modality for evaluating treatment 

 
9
response and contrast-enhanced computed tomography (CE-CT) is used when CE-MRI is contraindicated. 
However, there are multiple reasons patients may not undergo cross-sectional imaging follow-up - metallic 
implants, renal impairment, allergies to contrast medium, and anxieties related to confined space or 
radiation exposure. Additionally, the cost and availability of these techniques are disadvantageous 
compared to ultrasound imaging.   
 
Contrast-enhanced ultrasound (CEUS) is a well-established technique for enhancing echocardiograms in 
the United States and is approved for a wide range of vascular and oncologic applications worldwide. These 
contrast agents function as blood pooling agents and unlike the contrast agents used in MRI/CT, are not 
nephrotoxic and have no renal contraindications, making them an exceptionally safe imaging agent.  
Additionally, CEUS imaging is not influenced by residual Ethiodol or post-surgical inflammation in the 
liver, potentially offering an earlier option for monitoring treatment response of TACE compared to the 
current clinical standard. In this study, we propose a multi-center clinical trial to determine the sensitivity 
and specificity of two and real time three-dimensional (2D and 4D, respectively) CEUS for evaluating 
TACE.  In addition, quantitative biomarkers based on parametric imaging will be defined for identifying 
patients in need of retreatment. These techniques may provide a safer, more accurate imaging alternative 
for evaluating TACE effectiveness, as well as earlier identification of residual disease requiring retreatment. 
The multi-center nature of this proposed study allows sufficient sample sizes to define the sensitivity and 
specificity of CEUS within an adequate confidence interval, as well as investigate its operator and reader 
dependencies. Once properly validated, this technique is expected to improve patient outcomes by offering 
a viable imaging alternative in cases where CE-MRI/CT is contraindicated and enabling earlier 
identification of residual disease in need of retreatment. 
 
1.1 Background 
Hepatocellular carcinoma (HCC) is the fifth most prevalent cancer worldwide, with over half a million new 
cases reported per year [Alterkruse et al. 2009]. The rising incidence of HCC over the last 20 years is 
primarily attributed to the rise in hepatitis C virus infections [El-Serag and Mason 1999].  Surgery offers 
the best chance for long term cure; however, only 30% of referred patients are eligible for surgical resection, 
and this group is still plagued by 5 year recurrence rates higher than 70% [Bruix and Llovet 
2002].Transplantation is another treatment option for HCC, with the 5 year survival rates for liver 
transplantation at 68%, [Watt et al. 2010] yetis severely limited by tumor burden and the availability of 
donors [Kim et al. 2013; Llovet et al. 1999]. 
 
In patients with unresectable disease, locoregional treatment options include thermal ablation, 

 
10 
radioembolization and transarterial chemoembolization (TACE). Since hepatocellular cancers are almost 
exclusively supplied by the hepatic arterial system and the liver has a dual blood supply (approximately 
75% from the portal vein and 25% from the hepatic artery), trans-arterial treatment of tumors can be 
performed while limiting toxicity to the surrounding uninvolved parenchyma [Chapman et al. 2008; 
Gonsalves and Brown, 2009; Bruix and Sherman 2010]. While this technique is primarily used for the 
treatment of HCC, it has also been successful for a variety of hepatic malignancies [Burger et al. 2005; 
Herber et al. 2007; Giroux et al. 2004; Brown et al. 2012; Fiorentini et al. 2007; Patel et al. 2005; Sato et 
al. 2005; Madoff et al 2006].  
 
TACE involves the direct infusion of chemoembolic agents via a catheter placed in the tumor feeding artery 
[Yamada et al. 1995]. Conventional TACE (cTACE) uses chemotherapeutic agents mixed with Lipiodol, 
followed by an embolic material. Drug-eluting bead TACE (DEB-TACE) uses chemotherapeutic agents 
adsorbed onto poly-vinyl alcohol beads. The bead size is standardized and chosen based on tumor size and 
sub selective vascular access. Regardless of which embolic agents are used, the goal remains the same, to 
render the tumors ischemic while depositing high doses of chemotherapy in the tumor [Gonsalves and 
Brown 2009]. Tumor ischemia causes the disruption of intracellular glycoprotein pumps, which inhibits 
tumor cells from expelling chemotherapeutic agents, resulting in a six-fold increase in drug retention 
[Sasaki et al. 1987]. 
 
During cTACE, iodinated, ester derived poppy-seed oils serve as drug carriers, as temporary embolization 
material, and as imaging agents under fluoroscopy [Gonsalves and Brown, 2009]. The chemotherapeutic 
agents used may vary, but most frequently consist of a cisplatin, adriamycin, and mitomyocin (CAM) 
mixture [Van Ha 2009].  Following delivery, more permanent embolization is achieved with materials such 
as poly-vinyl alcohol or gelfoam [Gonsalves and Brown, 2009]. While cTACE is an effective therapy for 
slowing disease progression, improved patient responses with less toxicity have been observed with the use 
of DEB-TACE [Vogl et al. 2011; Lammer et al. 2010; Gaba 2012]. Embolization with DEB-TACE results 
in occlusion of the tumor vasculature, combined with a sustained, intratumoral release of the 
chemotherapeutic [Lewis et al. 2006].  Compared with cTACE, DEB-TACE is associated with greater 
treatment tolerance and significantly less liver toxicity and doxorubicin-related side effects [Vogl et al. 
2011, Lammer et al 2010].  
 
Both TACE procedures are performed under fluoroscopic guidance for catheter placement and infusion 
monitoring, with infusions continuing until near stasis in the tumor-feeding artery is observed [Van Ha 
2009]. Access to the tumor vasculature is achieved via a catheter placed in the hepatic artery. Technical 

 
11 
success, defined as correct catheter placement and drug administration, is achieved in approximately 98% 
of patients [Brown et al. 2012]. Residual tumoral viability at imaging post-embolization is the primary 
criterion used in determining the need to re-treat. TACE is frequently iterative – up to 65-75% of tumors 
will demonstrate residual blood flow and require repeat TACE or alternative treatments. The lack of 
efficacy on the initial treatment may be due to reaching premature stasis because of slow flow conditions, 
vasospasm limiting delivery, or redistribution of flow to the lesion from an alternative hepatic branch after 
primary branch occlusion.    
 
Contrast-enhanced magnetic resonance imaging (CE-MRI) is the standard imaging modality used to assess 
response to TACE by evaluating residual blood flow within the tumor [Brown et al. 2012; Hammerstingl 
et al. 2008; Akai et al. 2011]. The Society of Interventional Radiology guidelines recommend imaging 
follow-up four weeks post treatment [Brown et al. 2012]. A lack of arterial phase enhancement is used to 
indicate the lack of residual tumoral blood flow due to complete embolization and tumor necrosis. This one 
month time point has been adopted based on experience with the use of Lipiodol and on follow-up with 
contrast-enhanced computed tomography (CECT) scans; the non-tumor bearing liver requires 3-4 weeks to 
eliminate the Lipiodol by Kupffer cell phagocytosis [Brown et al. 2012]. In CE-MRI, the use of low 
molecular weight and water soluble contrast agents renders it difficult to differentiate granulation tissue 
and residual tumor perfusion and to differentiate peripheral viable tumors from inflammatory peritumoral 
infiltration if scanned within four weeks of treatment [Yan et al. 2002]. Differentiation between viable 
tumor and inflammation can be made in some cases by evaluating enhancement washout kinetics. 
Nevertheless, the cost of imaging and difficulty of inflammation in many cases has resulted in follow-up 
imaging recommendation to remain at 1 month [Brown et al. 2012]. CECT is used in patients in whom MRI 
is contraindicated. Confluent, dense Lipiodol uptake within treated tumors correlates with complete tumor 
necrosis, but may mask some residual tumor perfusion on CECT [Imaeda et al. 1993; Ito et al. 1995]. 
Following imaging, TACE or alternative treatment is repeated until a complete lack of arterial enhancement 
is achieved, after which tumoral response (evaluated by modified response evaluation criteria in solid 
tumors (mRECIST)) is assessed at 3-6 month intervals. 
 
While follow-up imaging standards are well established, several limitations exist. CE-MRI may not be 
feasible in patients with metallic implants, renal contraindications (glomerular filtration rates <30 mL/min/ 
1.73 m2 [Shellock and Spinazzi 2008]), the inability to breath hold or claustrophobia. CECT may be 
contraindicated in patients with severe allergy to iodinated contrast and renal impairment. The radiation 
exposure associated with repeated CT imaging (particularly in patients who undergo multiple TACE 
treatments) also renders CT a suboptimal imaging modality. Additionally, the costs and limited availability 

 
12 
of CE-MRI or CT may place a significant, unnecessary burden on the health system. A final limitation of 
existing imaging techniques is the required delay between treatment and imaging to evaluate response due 
to the inherent properties of the MRI/CT contrast media and the presence of Lipiodol in the background 
liver. Consequently, time to retreatment is prolonged and in patients where TACE is used to downstage 
disease, a decision regarding transplantation is delayed. Phase II efficacy and pharmacokinetic studies show 
liver function generally returns to normal within 7 days after DEB-TACE [Varela et al. 2007]; thus, 
retreatment before the standard 5-7 weeks is feasible. In addition, retreatment by ablation may also be 
performed earlier with advanced screening of effective embolization. An imaging test that provides earlier 
identification of tumoral blood flow after TACE would shorten the time between treatments and potentially 
improve patient outcomes. Once tumor avascularity is confirmed, patients could resume standardized CE-
MRI/CT long term follow-up protocols. 
 
We propose the use of contrast-enhanced ultrasound (CEUS) as a potential solution. Ultrasound contrast 
agents are composed of a gas microbubble, encapsulated by an outer protein or lipid shell [Goldberg et al. 
2001]. Ultrasound imaging is portable, provides real time imaging, uses non-ionizing radiation, is less 
expensive than CT/MRI, and is more readily available than MRI/CT imaging [Lewin 2004]. While CEUS 
is currently only approved by the FDA for echocardiography, the technique represents the primary imaging 
modality for numerous hepatic and vascular applications worldwide [Claudon et al. 2012; Bouakaz and de 
Jong, 2007]. CEUS also offers significant cost savings relative to CE-MRI/CT in the characterization of 
liver lesions [Westwood et al. 2013]. After intravenous injection, ultrasound contrast agents permeate 
throughout the blood supply, including the neovascular tumor supply, thereby providing enhancement of 
the tumor vasculature [Eisenbrey and Forsberg 2010]. The diameter of the contrast microbubbles (1-8 µm) 
enables them to pass through the pulmonary capillaries, but still restricts them to the vasculature, making 
them excellent intravascular blood pool agents [Correas et al. 2001]. Unlike the contrast agents used in 
MRI/CT, ultrasound contrast agents are not nephrotoxic and have no renal contraindications, making them 
an exceptionally safe imaging test. The presence of Lipiodol in the lesion does not interfere with ultrasound 
imaging. Unlike CT or MRI contrast agents, ultrasound contrast agents are completely confined to the 
vascular space and thus enable clear visualization of the tumor vasculature, despite any presence of 
inflammation. Finally, the higher temporal resolution of ultrasound avoids motion artifacts in patients with 
poor breath holding capability. Thus, CEUS is an attractive imaging alternative for identifying residual 
vascularity post-TACE.  
 
Recent technological advances in the field of medical ultrasound are expected to aid in these goals. 
Contrast-specific imaging techniques can isolate nonlinear microbubble signals from the surrounding tissue 

 
13 
to enhance visualization of vascularity [Philips 2004; Eisenbrey 2011a]. Additionally, the recent 
implementation of real-time 3D (i.e. 4D) transducers enables volumetric imaging at acceptable acquisition 
rates (2-6 volumes/second for 4D ultrasound vs. 20+ frames/ second for 2D ultrasound imaging) and image 
quality [Eisenbrey et al. 2012]. Finally, blood flow kinetics in tissue can be quantified using dynamic-CEUS 
(D-CEUS) or parametric imaging [Eisenbrey et al. 2011b] and these techniques have also been applied 
using 4D CEUS to enhance quantification of blood flow within a tissue volume [Sridharan et al. 2012]. 
 
Pilot studies by our groups suggest that 2D CEUS provides accurate and earlier identification of residual 
tumoral blood flow (relative to current imaging guidelines [Brown et al. 2012]) in TACE patients treated 
with Lipiodol [Kono et al. 2007] and drug-eluting beads [Shaw et al. 2014]. Importantly, results from our 
CEUS study with c-TACE also indicate that CEUS may be more accurate than CE-MRI/CT at 1 month for 
evaluating residual blood flow [Kono et al. 2007]. Other studies evaluating the use of 2D CEUS as a follow-
up imaging tool for TACE therapy reported that the lack of tumor enhancement correlates well with an 
avascular treatment response [Vallone et al. 2003; Salvaggio et al. 2010; Moschouris et al. 2010; Takizawa 
et al. 2013]. Xu et al. [2010] used static volumetric (3D) CEUS to monitor HCC response to local therapy 
and found the addition of volumetric ultrasound provided improved diagnostic confidence relative to 2D 
CEUS. Nevertheless, in this study, static 3D CEUS was used (potentially missing important dynamic 
volumetric data), only 12 patients underwent TACE therapy (and the majority of these TACE cases were 
treated in combination with ablation), effects of follow-up times were not investigated, and follow-up time 
ranged from 10 minutes to 28 months.  
 
Sufficient data relating to a contrast agent approved for use in the USA, the use of 4D volumetric CEUS, 
the influence of reader or operator dependence, or the effect of follow-up time of CEUS for evaluating 
TACE therapy are not available. Additionally, D-CEUS remains a relatively unexplored option for 
characterizing treatment response to TACE therapy and may offer further improvements in diagnostic 
accuracy. Such findings could provide a safe, cost-effective and readily available follow-up imaging 
alternative, while also potentially improving patient outcomes by providing earlier and more accurate 
identification of patients requiring re-treatment. We propose a multi-center clinical trial to determine the 
sensitivity and specificity of 2D and 4D CEUS for evaluating TACE 1-2 weeks and 1 month post-treatment. 
 
The proposed agent for the current study, Definity is a sterile non-pyrogenic suspension of liposome-
encapsulated perfluoropropane microbubbles [Goldberg et al 2001; Miller & Nanda 2004].  The contrast 
agent is composed of a blend of three phospholipids contained in a matrix of sodium chloride, propylene 
glycol, and glycerin in water.  The contrast agent is supplied in a vial that contains the phospholipids and 

 
14 
perfluouropropane gas.  The microbubble agent is supplied in a standard-size 2 ml vial and is prepared by 
shaking the vial with the aid of a shaking device (Vialmix: ESPE, Seefeld, Germany).   
 
Definity is currently only approved for use in echocardiography.  The agent will be used as an off-label 
indication for this study.  We intend to apply for an FDA investigator-instantiated IND for the off-label 
usage of Definity for the evaluation of chemoembolization. 
 
Definity Clinical Safety 
Definity is well tolerated and has been used extensively in echocardiography applications [Goldberg et al 
2001].  In pre-market clinical trials, Definity was administered to 1716 patients.  In these patients 269 
(8.4%) reported at least one adverse event.  Of these events, 26 were classified as serious including 19 
(1.1%) patients experiencing serious cardiopulmonary symptoms including eight deaths.  The deaths 
occurred several days after activated Definity administration and appear to be related to the course of 
underlying disease.  Of the 11 other serious adverse events, which appeared within days of the drug 
administration (2-15 days), all appeared to be a progression of underlying cardiac and non-cardiac disease.  
However, a role for Definity in the initiation or course of these adverse events can not be ruled out. Of the 
reported adverse reactions following the use of Definity the most frequently reported were headache (2.3%), 
back and renal pain (2.1%), flushing (1.1%), and nausea (1.0%).  Additional risks associated with the 
contrast material are described in the attached Definity Product insert (Appendix B). All of the non-serious 
reported side effects have been transient, usually lasting only a few minutes.   
 
Table 1. 
Selected Adverse Events Reported in ≥ 0.5% of the Subjects who Received Definity in Controlled Clinical 
Studies 
 
No. of Patients Exposed to Definity 
 
1716 
 
 
No. of Patients Reporting an Adverse Event 
269  
(8.8%) 
Central and peripheral nervous system 54  
(3.2%) 
 
Headache 
 
 
40  
(2.3%) 
 
Dizziness 
 
 
11  
(0.6%)  
Body as a Whole 
 
 
41 
(2.4%) 
 
Back/Renal Pain 
 
20  
(1.2%) 
 
Chest Pain 
 
 
13  
(0.8%) 
Digestive System 
 
 
31 
(1.8%) 
 
Nausea  
 
 
17 
(1.0%) 
Vascular (extracardiac) disorders 
19 
(1.1%) 
 
Flushing 
 
 
19 
(1.1%) 
Application Site Disorders 
 
11 
(0.6%) 
 
Injection Site Reactions  
11 
(0.6%) 

 
15 
 
Additional information concerning pre-clinical and clinical experience with Definity, including the dosing 
levels and reported subject complaints, can be found in the Definity Package Insert that is included as 
Appendix B. 
 
1.2  Rationale 
Successful TACE of a tumor using drug eluting beads is expected to completely obstruct the tumor blood 
supply. Thus, the fundamental theory behind this study is that CEUS, which uses a blood pooling agent for 
contrast, will provide a good indicator of the degree of occlusion. If CEUS at one month correlates with the 
current clinical standard of a contrast-enhanced MRI, this alternative will lead to substantial cost savings. 
If CEUS at one to two weeks correlates with the current clinical standard of a contrast-enhanced MRI at 
one month, this will reduce time to retreatment, potentially improving patient outcomes.   
 
We propose a clinical trial to determine the accuracy of using CEUS for the evaluation of TACE of HCC.  
The purpose of this study is to compare ultrasound derived vascularity and blood flow measurements at 
varying time intervals to both the clinical evaluation standard and patient outcomes.  
 
2.   TRIAL OBJECTIVES 
 
Trial Objectives: The primary objective of this trial is to: 
- 
To evaluate the sensitivity and specificity of 2D and 4D contrast enhanced ultrasound for 
monitoring transarterial chemoembolization (TACE) response 1-2 weeks and 1 month post 
treatment as an alternative to contrast-enhanced magnetic resonance (MRI) or computed 
tomography (CT) imaging 
 
The secondary aim of this trial is to: 
- 
To develop quantitative biomarkers based on the ultrasound contrast agent kinetics for identifying 
patients requiring retreatment of residual disease.   
 
3. TRIAL DESIGN 
This is an open-label, non-randomized trial that will be conducted at three clinical sites.  The subject 
population will be patients undergoing transarterial chemoembolization for the treatment of hepatocellular 
carcinoma (HCC) at Thomas Jefferson University, The University of California, San Diego, and The 
Hospital of the University of Pennsylvania. Patients will receive a contrast-enhanced ultrasound (CEUS) 
exam the morning prior to embolization, approximately one week post-embolization, and at their one month 

 
16 
MRI follow up (scheduled as part of their clinical standard of care). 
 
3.1  Trial Duration 
Individual participation in this trial will be limited to three ultrasound imaging studies. Exams will take 
place the morning prior to treatment, one to two weeks post embolization, and prior to the patient’s one 
month follow-up (scheduled as part of clinical care). If the patient fails to show up for the one week, CEUS 
exam, they will not be excluded from the final ultrasound exam. The entire ultrasound imaging protocol 
will require approximately one hour including a 30 min observation period. Patients will be monitored for 
at least 30 minutes before being escorted to procedure or clinically scheduled imaging. 
 
Subject recruitment is expected to last 5 years (January 2016 – December 2020). Analysis and publication 
of results are expected to take an additional 2 months (December 2020– January 2021).  Volunteer Registry 
Database forms will be submitted to the National Institute of Health’s Office of Regulatory Compliance 
and Quality at the completion of the research study.   
 
4.  TRIAL POPULATION 
Trial Population: This trial will consist of up to 210 adults (with a maximum of up to 100 at any institution) 
undergoing transarterial chemoembolization for the treatment of HCC split between Thomas Jefferson 
University, The University of California, San Diego, and The Hospital of the University of Pennsylvania. 
The patients enrolled in this project will be adults over the age of 21 capable of providing informed consent. 
 
4.1  Inclusion Criteria 
All subjects accepted for this trial must: 
• Patients ≥ 21 years of age 
• Patient capable of making informed decisions regarding his/her treatment 
• 
Scheduled for TACE treatment of a HCC mass (lesions reported as Liver Imaging  Reporting 
and Data Systems 4B or 5 or Organ Procurement and Transplantation Network 5a or 5b)  
• Negative pregnancy test in a female of child-bearing age (regardless of sexual orientation, 
having undergone a tubal ligation, or remaining celibate by choice) who meets the following 
criteria 
o  Has not undergone a hysterectomy or bilateral oophorectomy; OR 
o Has not been naturally postmenapasual for at least 12 consecutive months (i.e., has had 
menses at any time in the preceding 12 consecutive months) 
• Have an HCC mass viewable on grayscale B-mode ultrasound. 
 
4.2  Exclusion Criteria 

 
17 
Subjects with any of the following conditions or who have had the following procedures will be excluded 
from this trial: 
• Females who are pregnant or nursing. 
• Patients not eligible or scheduled for TACE of a HCC mass. 
• Patients who have received an investigational drug in the 30 days before study drug 
administration,    or will receive one within 72 h after their final CEUS exam. 
• Patients who have received prior radioembolization (Y90) of the lesion of interest. 
• Patients with known or suspected hypersensitivity to perflutren 
• Patients with pulmonary hypertension or unstable cardiopulmonary conditions. 
• Patients who are medically unstable, terminally ill, or whose clinical course is unpredictable.   
 
Subject identification will be maintained with a study specific alphanumeric code including the study site 
(TJU, HUP, UCSD) and study number (01-100).  
 
Subsite Enrollment Procedures 
When a potential patient is identified at the sub-site, the Thomas Jefferson University (TJU) Study Site 
Contact should be contacted within 1 week via email or phone. Please see the Site Contact List for email 
and phone number for the TJU Study Site Contact. The sub-site will send the following to the TJU Study 
Site Contact 
1. Notify them of the patient registration 
2. Confirm the method of sending registration documents (i.e. fax, email, etc.) 
3. Communicate the desired timeline of study completion. 
 
A master study enrollment log will be maintained by the study team at Thomas Jefferson 
University. The sub-site site will also be asked to maintain an enrollment/screening log on-site, 
and email this information to the TJU Study Site Contact at least once a month.  
 
 
5. MEDICATIONS 
Definity will be provided by Lantheus Medical Imaging, Billerica, MA.  An FDA Sponsor-Investigator 
IND will be obtained prior to beginning the trial. 
 
Definity is a sterile, non-pyrogenic suspension of liposome-encapsulated perfluoropropane microbubbles 
[Goldberg et al 2001; Miller & Nanda 2004].  The contrast agent is composed of a blend of three 
phospholipids contained in a matrix of sodium chloride, propylene glycol, and glycerin in water.  The 
contrast agent is supplied in a vial that contains the phospholipids and perfluouropropane gas.  The 
microbubble agent is supplied in a standard-size 2 ml vial and is prepared by shaking the vial with the aid 

 
18 
of a shaking device (Vialmix: ESPE, Seefeld, Germany).  Detailed resuspension instructions are provided 
in the Definity Product Insert, found in Appendix B. 
 
Definity will be stored in a secure cabinet, with only the study investigators and research personnel 
having access.  Unused drug and empty vials will be properly disposed of after reconciling in the log of 
study drug. 
 
5.1 Administration 
All contrast injections will be supervised by a board certified physician. Resuscitation equipment and 
trained personnel will be immediate proximity to the patient during each contrast-enhanced ultrasound 
exam. Definity will be administered by bolus IV injection through an 18- to 20-gauge angiocatheter placed 
in a peripheral arm vein, preferably an antecubital vein.  Subjects will be instructed not to move their arm 
during the administration of the contrast agent.  Subjects will receive a bolus injection of up to 0.6 ml. All 
injections will be performed at a steady rate not to exceed 1 ml/sec. If contrast is not detected within the 
tumor, the injection may be repeated with the total cumulative dose not to exceed 1.5 ml. Each bolus 
injection of Definity will be followed with a very slow flush of 10 ml of normal saline. 
 
5.2 Contraindications  
Definity should not be administered to patients with known or suspected hypersensitivity to perflutren. The 
safety of Definity in patients with  1) severe emphysema, pulmonary vasculitis or a history of pulmonary 
emboli; 2) confirmed or suspected severe liver lesions; and 3) respirator distress syndrome has not been 
studied.  Therefore, patients with any of these conditions will be excluded from participation. 
 
5.3  Randomization 
This is a non-randomized trial; therefore, no randomization procedure is required. 
 
5.4 Blinding and Unblinding Methods 
This is an open-label trial; therefore, no blinding or unblinding procedures for the trial drug are required.  
 
5.5  Storage 
Definity vials will be stored in a secure refrigerator, with only the study investigators and research personnel 
having access.  The study research nurse will be responsible for drug suspension and inventory control. 
 
6.  TRIAL PROCEDURES 

 
19 
6.1 Patient Enrollment  
Patients will be identified and consecutively approached from each institution’s Hepatology / Transplant 
Surgery and Interventional Radiology practices (by each site’s Hepatology or Interventional Radiology co-
investigators). An investigator or research coordinator will explain the study to the patient. The patient will 
be given time to consider the risks and benefits of the study and to ask questions about participation. A 
consent form will be reviewed with the patient 
 
6.2 Screening Assessments 
Trial participants will have the presence of inclusion criteria and absence of exclusion criteria verified by 
providing a medical history.  A full history and physical examination will be obtained from the patient’s 
referring physician.  If the subject is a woman of childbearing age as defined in the inclusion criteria (section 
4.1), she will have a urine pregnancy test prior to each CEUS study (the results of which will be made 
available to the subject prior to study initiation). In the event a patient presents with a lesion that is expected 
to be difficult to view on ultrasound (for example, smaller lesions located high on the liver dome), grayscale 
ultrasound imaging will quickly be performed to ensure the lesion is visible on ultrasound and that the 
patient is suitable for study inclusion. Based on preliminary studies, approximately 10-30% of TACE 
patients will present with lesions that are not detectable on baseline ultrasound (generally a smaller, 
nonvisible percentage compared to traditional liver mass ultrasound characterization studies). Particular 
issues tend to arise in cirrhotic patients with smaller lesions at the dome of the liver [Kono et al. 2007]. 
Patients with masses not visible on B-mode ultrasound will be treated as failed cases and reported, but not 
followed with CEUS or counted towards our 210 enrollment limit for the work proposed in our specific 
aims. 
 
6.3 Ultrasound Imaging 
Patients will first undergo 2D baseline imaging.  B-mode measurements and sweeps of the lesion in the 
transverse and sagittal planes will be performed, followed by standard power Doppler imaging (PDI). 
Following baseline imaging, patients will receive a bolus IV injection of up to 0.6 ml of Definity, followed 
by a 10 cc saline flush. Since Definity is currently only approved for echocardiography, we will apply to 
the FDA for an investigational new drug application for CEUS evaluation of TACE (similar to our previous 
study [Shaw at el. 2014]).  
 
All CEUS imaging will be performed using the dual B-mode (used to locate anatomical features) and 
nonlinear contrast (to identify the ultrasound contrast agent) imaging mode. A low mechanical index (< 
0.1) will be used to minimize microbubble destruction during imaging. The standard nonlinear imaging 

 
20 
frequency pairings in the contrast imaging software will be used (transmitting at 2 MHz, receiving at the 4 
MHz harmonic), and gain settings will be adjusted to minimize nonlinear signals prior to contrast injection. 
Additionally, the focal zone will be placed at the approximate depth of the lesion to maximize the generation 
of nonlinear signals during CEUS. During the first contrast injection, 2D CEUS will be performed using 
the coded harmonics nonlinear imaging package on the unit. The approximate tumor mid-line will be 
imaged until homogenous liver enhancement is achieved (approximately 45 seconds post injection), 
followed by imaging sweeps through the tumor. Sweeps will then be acquired in the sagittal plane, before 
returning to the original plane. Imaging will be continued until contrast washout is observed (approximately 
3-4 minutes), after which data will be digitally stored for later review. A ten to fifteen minute wait period 
will be observed between injections to allow for complete ultrasound contrast agent clearance. A region of 
interest encompassing the entire tumor volume and margin will then be selected in 4D mode.  Baseline 
imaging of the tumor will be repeated in 4D mode in grayscale B-mode. The line density (a measure of 
image quality) may also be adjusted to achieve adequate volume acquisition rates (>0.5 volumes/ second). 
A second bolus injection of up to 0.6 ml Definity followed by 10 cc saline flush will again be administered 
during continuous tumor imaging in 4D, which uses the machine’s coded harmonics package. If sufficient 
contrast is not detected in either mode, the injection may be repeated with the total cumulative study dose 
not to exceed 1.5 ml. Data will be obtained until contrast washout is observed and then digitally stored in 
digital imaging and communications in medicine (DICOM) format for later review. 
 
6.4  Safety Monitoring 
Patients will be monitored for AEs during and 30 mins after contrast administration. All other procedures 
will be performed according to standard of care. 
 
6.5 Efficacy Assessments 
Following reader training, each reader (all of whom have previous experience with CEUS and volumetric 
ultrasound) will be asked to evaluate all 201 remaining cases. 2D and 4D CEUS exams will be read 
separately and only after randomization. Readers will first be asked to review both the patient’s baseline 
CE-MRI/CT and CEUS exams to identify the size and location of the treated mass. Following baseline 
review, each reader will review the 1-2 week and 1 month CEUS exam (in random order). Intratumoral 
blood flow will be assessed as present or not present. Readers will then be asked to interpret the patient’s 
1 month follow-up CE-MRI/CT images and again evaluate the need to retreat based on residual blood 
flow. Finally, when available, readers will review subsequent CE-MRI/CT imaging studies (up to six 
months post TACE). MRI/CT evaluations will be based on mRECIST criteria.  All imaging studies will 
be read twice by each reader. Studies will be presented in random order. The second round reads will be 

 
21 
performed at least one month after the first. Outcomes will be defined as incompletely treated (i.e. 
requiring retreatment) based on (in order of preference of reference standard): a) pathological 
examination of explanted livers demonstrating live tumors; b) tumor enhancement seen with CT or MR 
and confirmed via angiography during retreatment; c) tumor growth on 6 month follow-up CE-CT/MRI; 
or d) asymmetrical or nodular tumor enhancement on CE-MRI/CT on 6 month follow-up. Incomplete 
treatment on CEUS (2D or 4D) will be evaluated by each reader and evidenced by the tumor showing 
either residual blood flow after treatment or nodular peripheral blood flow. 
 
Quantitative analysis of 2D and 4D CEUS datasets will be performed off-line using Matlab (Mathworks, 
Natick, MA). Motion compensation will first be performed using modified approaches of a either a kernel 
matching [Dave et al. 2009] or a dual mode registration [Bouhlel et al. 2014] motion compensation 
technique. Parametric images of both the mass and surrounding liver tissue will be generated using 2D 
[Eisenbrey et al. 2011b] and 4D [Sridharan et al. 2014] algorithms previously developed by our lab to 
quantify maximum intensity, perfusion, time to peak, and area under the time intensity curve.  Based on 
images or volumes from the arterial wash-in phase, images will be cropped to include the tumor and 
margins of 20% of the mass diameter. Vascular skeletonization of the mass and surrounding margins will 
then be performed [Eisenbrey et al. 2011c] and fractal dimensionality of the skeletonized images 
calculated (another potential quantifiable indicator of malignancy [Taverna et al. 2009]). Differences in 
all quantified parameters between pre- and post- treatment will then be calculated and compared between 
groups to determine if significant biomarkers exist in identifying patients in need of re-treatment. 
 
6.6 Safety Assessments 
6.6.1 Unanticipated Problems 
Unanticipated problems (UAPs) include, in general, any incident, experience, or outcome that meets the 
following criteria: 
• 
unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the IRB-approved research protocol and 
informed consent document; and (b) the characteristics of the participant population being 
studied; 
UAPs are considered to pose risk to participants or others when they suggest that the research places 
participants or others at a greater risk of harm (including physical, psychological, economic, or social 
harm) than was previously known or recognized. 
 
6.6.2  Adverse Events 

 
22 
An adverse event is any untoward or unfavorable medical occurrence in a human participant, including 
any abnormal sign (for example, abnormal physical exam or laboratory finding), symptom, or disease, 
temporally associated with the participant’s participation in the research, whether or not considered 
related to the participant’s participation in the research. 
 
6.6.3 Serious Adverse Events 
A serious adverse event (SAE) is one that meets one or more of the following criteria: 
• 
Results in death 
• 
Is life-threatening (places the participant at immediate risk of death from the event as it occurred) 
• 
Is disabling or incapacitating 
• 
Results in inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in a persistent or significant disability or incapacity 
• 
Results in a congenital anomaly or birth defect  
• 
An important medical event that may not result in death, be life threatening, or require 
hospitalization may be considered an SAE when, based upon appropriate medical judgment, the 
event may jeopardize the participant or may require intervention to prevent one of the outcomes 
listed in this definition. 
 
6.6.4 Safety Assessment and Follow-Up 
The PI will follow adverse events with start dates occurring any time after informed consent is obtained 
until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation. At each study 
visit, the investigator (or designee) will inquire about the occurrence of AE/SAEs since the last visit. 
Events will be followed for outcome information until resolution or stabilization. 
 
The subjects will be monitored for AEs during the entire procedure.  All AEs, including observed or 
volunteered problems, complaints, signs or symptoms, and diagnoses, occurring from the initiation of 
Definity dosing until 30 minutes from the completion of the Definity administration will be recorded on a 
serious or non-serious AE data form, whether or not associated with the use of the trial medication.   
 
6.6.5 Recording Adverse Events 
The following subsections detail what information must be documented for each adverse event occurring 
during the time period specified in Section 6.6.4.  
 
Relationship to Study Intervention 

 
23 
The relationship to study intervention or study participation must be assessed and documented for all 
adverse events. Evaluation of relatedness must consider etiologies such as natural history of the 
underlying disease, concurrent illness, concomitant therapy, study-related procedures, accidents, and 
other external factors.  
 
The following guidelines are used to assess relationship of an event to study intervention: 
Relationship 
1. Related (Possible, Probable, Definite) 
a. The event is known to occur with the study intervention. 
b. There is a temporal relationship between the intervention and event onset. 
c. The event abates when the intervention is discontinued. 
d. The event reappears upon a re-challenge with the intervention. 
2. Not Related (Unlikely, Not Related) 
a. There is no temporal relationship between the intervention and event onset. 
b. An alternate etiology has been established. 
Expectedness 
The PI is responsible for determining whether an AE is expected or unexpected. An AE will be 
considered unexpected if the nature, severity, or frequency of the event is not consistent with the risk 
information previously described for the intervention. Risk information to assess expectedness can be 
obtained from preclinical studies, the investigator’s brochure, published medical literature, the protocol, 
or the informed consent document. 
Severity of Event 
Adverse events will be graded for severity according to the Common Terminology Criteria for Adverse 
Events (CTCAE) version 4.0 
Intervention 
Any intervention implemented to treat the adverse event must be documented for all adverse events. 
 
6.6.6 Safety Reporting 
Reporting to the IRB 
Unanticipated Problems 
All incidents or events that meet criteria for unanticipated problems (UAPs) as defined in Section 6.6.1  
require the creation and completion of an unanticipated problem report form (OHR-20).  

 
24 
UAPs that pose risk to participants or others, and that are not AEs, will be submitted to the IRB on an 
OHR-20 form via the eazUP system within 5 working days of the investigator becoming aware of the 
event.  
UAPs that do not pose risk to participants or others will be submitted to the IRB at the next continuing 
review.  
Sub-Site Unanticipated Problems Reporting 
Unanticipated problems (UAPs) occurring at the sub-site are to be reported to the sub-site IRB 
per institutional guidelines. 
UAPs occurring at the sub-site must also be reported to Thomas Jefferson University using the 
Unanticipated Problems Form (see Appendix C). The TJU Study Site Contact will submit UAPs 
occurring at the sub-site to the TJU IRB. 
Adverse Events  
Grade 1 AEs will be reported to the IRB at continuing review.  
Grade 2 AEs will be reported to the IRB at the time of continuing review.  
Serious Adverse Events  
SAEs will be reported to the IRB on OHR-10 forms via the electronic reporting system (eSAEy) 
according to the required time frames described below. 
Grade 3-4 AEs that are unexpected and deemed to be at least possibly related to the study will be reported 
to the IRB within 2 working days of knowledge of the event. 
Grade 3-4 AEs that are deemed unrelated to the study will be reported to the IRB within 5 working days.  
Grade 5 AEs will be reported to the IRB within one working day of knowledge of the event. 
All SAEs will be submitted to the IRB at continuing review, including those that were reported 
previously. 
SAEs occurring at the sub-site are to be reported to the sub-site IRB per institutional guidelines.  
Sub-Site SAE Reporting 
All SAEs occurring at the sub-site must be reported to the TJU Study Site Contact within 24 
hours of notification. This initial notification can take place via email or phone, followed by the 
submission of a formal report.   
SAEs should be reported to TJU using the FDA Medwatch 3500A, and should comprise a full 
written summary, detailing relevant aspects of the adverse events in questions, including grading 

 
25 
and attribution to study drug.  Where applicable, information from relevant hospital case records 
and autopsy reports should be included.   
SAE Reports should be signed by the sub-site PI, and then emailed to the Thomas Jefferson 
University Study Site Contact within 24 hours.  
The TJU coordinator will notify the TJU PI and obtain the TJU PI signature, and report these 
events to the TJU Medical Monitor/IRB appropriately (within 5 working days if it deems an 
amendment, or in a spreadsheet at the time of annual review if no amendment is necessary). 
Additional follow-up SAE reports should be submitted when available. 
All reportable Adverse Events (AEs) should be reported to the TJU Research Coordinator within 
48 hours using the FDA MedWatch 3500 form.  
A reportable AE is any adverse event NOT identified in the IB or consent form as a risk.  
Any non-reportable AE must be kept by the sub-site on an ongoing tracking log to be reviewed 
by TJU quarterly. 
Unanticipated problems (UAPs) that pose risk to subjects or others, and that are not AEs/SAEs 
should be reported to TJU within 10 working days using form Unanticipated Problems Form (see 
Appendix C) and should be emailed to the TJU Study Site Contact within 5 business days.   
 
Reporting to the Sidney Kimmel Cancer Center DSMB 
All AEs and SAEs, safety and toxicity data, and any corrective actions will be submitted to the DSMC 
per the frequency described in the SKCC DSMP. The report to SKCC DSMC will also include any 
unanticipated problems that in the opinion of the PI should be reported to the DSMC. 
The sub-site is required to provide copies of any Unanticipated Problems, protocol deviations, and AE 
logs to the TJU Study Site Contact for submission to the DSMC. 
 
For expedited reporting requirements, see table below: 
DSMC AE/SAE Reporting Requirements 

 
26 
 
FDA Reporting 
The investigator is required to submit all unexpected and serious adverse events to the FDA within 48 
hours.  Fatal adverse events related to treatment which are unexpected must be reported within 24 hours. 
Fatalities not related to the study drug/device must be reported within 5 days. 
Thomas Jefferson University will submit SAE reports for all sites to the FDA. 
 
SAEs should be reported on MedWatch Form 3500A, which can be accessed at: 
http://www.accessdata.fda.gov/scripts/medwatch/. 
 
MedWatch SAE forms should be sent to the FDA at: 
MEDWATCH 
5600 Fishers Lane 
Rockville, MD 20852-9787 

 
27 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
http://www.accessdata.fda.gov/scripts/medwatch/ 
 
The TJU Study Site Contact is responsible for submitting all SAE reports occurring at TJU and the sub-site 
to the FDA. 
 
6.7  End-of-Treatment and End-of-Trial Evaluations 
6.7.1  Discontinuation of Subjects 
Subjects will be free to discontinue trial participation at any time.  The investigator will also discontinue 
any subject from the trial if, in the investigator's opinion, it is not safe for the subject to continue.  The date 
the subject is withdrawn from a treatment and/or from the trial and the reason for discontinuation will be 
recorded on the CRF. 
 
Trial participation will be considered completed if the subject has met all of the following trial requirements: 
• 
Has received three contrast-enhanced ultrasound exams 
• 
Has undergone the one month contrast-enhanced follow up MRI scheduled as part of their clinical 
care. 
 
If a subject's participation in the trial is interrupted for any reason (e.g., because of an AE or if the subject 
is lost to follow-up) and the subject has met the criteria described above for completing the trial, the subject's 
trial participation will be considered completed.  If a subject's trial participation is interrupted for any reason 
by the subject's or investigator's choice and the subject has not met all of the criteria listed above, then the 
subject will be considered a discontinued subject. 
 
7.  DATA MANAGEMENT AND STATISTICAL ANALYSES 
 
7.1  Data Management 
 
Data forms will be completed for all subjects enrolled in the trial.  The subject study files will be stored in 
a secure file cabinet and maintained by the research study coordinator.  Subject study files will be kept for 
7 years after the completion of the study.   
 
The final data will be entered into a database.  The investigator will be responsible for management of the 
database.  The database will be maintained within an organized and secure directory system. 

 
28 
7.1.1 Sub-Site Data Management 
Data forms will be completed by sub-site research staff for all subjects enrolled at the sub-site. Completed 
data forms must be sent to Thomas Jefferson University for inputting into the database. Image data will be 
de-identified, transferred to Thomas Jefferson University, and placed on a secure server.  
 
7.2 Statistical Analyses 
Data analysis from this multi-center clinical trial will be performed to characterize 2D and 4D CEUS as a 
follow-up imaging tool for the evaluation of residual tumoral blood flow in patients with HCC treated with 
TACE.   
Our statistical analysis will address three major questions:   
1.  Does 2D and 4D CEUS 1-2 weeks post TACE yield sensitivity and specificity greater than 90%  
for identifying residual tumor blood flow, thereby providing reliable earlier identification (relative 
to the current clinical standard) of patients in need of retreatment? 
2. Does 2D and 4D CEUS 1 month post TACE yield sensitivity and specificity greater than 90% for 
identifying residual tumor blood flow ,thereby providing an accurate, safe, and cost-effective 
imaging alternative for identifying TACE patients in need of retreatment? 
3. Are quantifiable biomarkers generated by parametric imaging of 2D and 4D CEUS exams able to 
differentiate between fully treated and incompletely treated masses by measuring blood flow 
kinetics? 
 
The first three cases at each institution will be used as reader training cases and will not be included in the 
final analysis. In the event of all cases showing identical response (i.e. all incompletely or completely 
treated), the first case with an alternative outcome will be substituted for the 9th case. Following reader 
training, each reader (all of whom have previous experience with CEUS and volumetric ultrasound) will be 
asked to evaluate all 201 remaining cases. 2D and 4D CEUS exams will be read separately and only after 
randomization. 2D cases will be viewed in a standard DICOM viewer, while 4D cases will be viewed in 
GE’s 4D View software. Readers will first be asked to review both the patient’s baseline CE-MRI/CT and 
CEUS exams to identify the size and location of the treated mass. Following baseline review, each reader 
will review the 1-2 week and 1 month CEUS exam (in random order). Intratumoral blood flow will be 
assessed as present or not present. Readers will then be asked to interpret the patient’s 1 month follow-up 
CE-MRI/CT images and again evaluate the need to retreat based on residual blood flow. Finally, when 
available, readers will review subsequent CE-MRI/CT imaging studies (up to six months post TACE). 
MRI/CT evaluations will be based on mRECIST criteria. All imaging studies will be read twice by each 

 
29 
reader. Studies will be presented in random order. The second round reads will be performed at least one 
month after the first. Outcomes will be defined as incompletely treated (i.e. requiring retreatment) based on 
(in order of preference of reference standard): a) pathological examination of explanted livers 
demonstrating live tumors; b) tumor enhancement seen with CT or MR and confirmed via angiography 
during retreatment; c) tumor growth on 6 month follow-up CE-CT/MRI; or d) asymmetrical or nodular 
tumor enhancement on CE-MRI/CT on 6 month follow-up. Incomplete treatment on CEUS (2D or 4D) will 
be evaluated by each reader and evidenced by the tumor showing either residual blood flow after treatment 
or nodular peripheral blood flow.   
 
For questions 1-2, sensitivity (the ability to detect patients in need of retreatment) and specificity (the ability 
to identify patients who do not require retreatment) will first be calculated on a reader by reader basis. Four 
2 x 2 tables will be constructed comparing the need for re-treatment based on the clinical gold standard 
described above and CEUS, tabulating true positives, false positives, false negatives, and true negatives. A 
table will be created for CEUS at 1-2 weeks and 1 month for both 2D and 4D CEUS and used to calculate 
sensitivity, specificity, accuracy, positive predictive value, and negative predictive value. Statistical 
significance between the reference standard and each of the 4 CEUS groups will be determined using a 
McNemar test.   These values will also be calculated based on the majority decision (i.e. 4 or more readers 
in agreement). In the event of discordant readings during this analysis, tumor outcome will be decided by 
consensus by the two readers at TJU.  Differences between techniques (2D vs. 4D) and time points (1-2 
weeks vs. 1 month post treatment) will be determined by comparing areas under the receiver operating 
characteristic curves for each modality/time point based on necessity of tumor retreatment. Intra-rater and 
inter-rater variability will be calculated using a Shrout and Fleiss Interclass Correlation [Shrout and Fleiss 
1979]. Finally, a logistical regression and analysis of variance will be performed to determine if significant 
variations exist between individual sites (to determine operator dependence), lesion size (tumor size 
dependency) or between patients treated with cTACE vs. DEB-TACE (treatment dependency). 
 
 For statistical question 3, all quantitative parameters will be compared between fully treated and 
incompletely treated masses using a Student’s t-test. Additionally, lesions that demonstrate lack of residual 
enhancement at 1 month, but show recurrence at 6 month follow-up, will be compared to completely treated 
masses to determine if quantitative CEUS parameters can detect this lower level of residual disease. 
Statistical analysis will be performed with assistance from the biostatistician co-investigator using Stata 
12.0 (Stata Corp, College Station, TX) with p values < 0.05 considered statistically significant after a 
Bonferroni-type adjustment for multiple tests. These statistical tests will answer our three major questions 
regarding the sensitivity and specificity of 2D and 4D CEUS as an imaging tool for the follow-up of TACE 

 
30 
at 1-2 weeks and 1 month (specific aims 1-2), as well as the influence of operator, reader, tumor size, and 
embolization material. 
 
7.2.1  Sample Size Justification  
As the most clinically important aims, aims 1-2 will be used as the basis for the sample size analysis, where 
each patient represents an independent data point used to evaluate the technique’s sensitivity and specificity 
at both 1-2 weeks and 1 month follow-up times. Based on our pilot studies using 2D CEUS to evaluate 
TACE performed using Lipiodol [Kono et al. 2007] or drug-eluting-beads [Shaw et al. 2014], we expect to 
encounter a patient population in which up to 67% of patients require retreatment. A sample size analysis 
was performed using a binomial test with One-Sample Sensitivity and Specificity Analysis in NCSS/PASS 
2008 (NCSS, East Kaysville, UT) to estimate the number of cases required to produce a over 85% power 
for this study. This analysis assumes sensitivity and specificities of 98%, an alpha of 0.05, prevalence of 
disease of 66.7%, and null sensitivity and specificities of 90%. Results from this analysis are provided in 
tabular format below. 
 
 
 
--- Sensitivity --- 
--- Specificity --- 
------------- Alpha ------------
 
Preva- 
----- Power ------ 
Sample 
Size 
H0 
H1 
H0 
H1 
 
Sens. 
Spec. 
lence 
Sens. 
Spec. 
N1 and N 
Se0 
Se1 
Sp0 
Sp1 
Target 
Actual 
Actual 
P   
0.0000 
0.0000 
7 
10 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0000 
0.0000 
0.6670 
0.0000 
0.0000 
13 
20 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0000 
0.0000 
0.6670 
0.0000 
0.0000 
20 
30 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0000 
0.0000 
0.6670 
0.0000 
0.0000 
27 
40 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0000 
0.0000 
0.6670 
0.5134 
0.0000 
33 
50 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0309 
0.0000 
0.6670 
0.4457 
0.0000 
40 
60 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0148 
0.0000 
0.6670 
0.7581 
0.0000 
47 
70 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0440 
0.0000 
0.6670 
0.7135 
0.0000 
53 
80 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0259 
0.0000 
0.6670 
0.6619 
0.5455 
60 
90 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0138 
0.0424 
0.6670 
0.8494 
0.5134 
67 
100 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0307 
0.0309 
0.6670 
0.8202 
0.4735 
73 
110 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0190 
0.0203 
0.6670 
0.9231 
0.4457 
80 
120 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0353 
0.0148 
0.6670 
0.9027 
0.4195 
87 
130 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0211 
0.0108 
0.6670 
0.9608 
0.7581 
93 
140 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0382 
0.0440 
0.6670 

 
31 
0.9492 
0.7358 
100 
150 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0237 
0.0338 
0.6670 
0.9791 
0.7135 
107 
160 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0374 
0.0259 
0.6670 
0.9735 
0.6839 
113 
170 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0255 
0.0181 
0.6670 
0.9893 
0.6619 
120 
180 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0382 
0.0138 
0.6670 
0.9857 
0.8879 
127 
190 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0250 
0.0421 
0.6670 
0.9945 
0.8494 
133 
200 
0.9000 
0.9800 
0.9000 
0.9800 
0.0500 
0.0385 
0.0307 
0.6670 
 
A total of 201 patients will be used in the final analysis for this study (the first 9 will be used as training 
cases and excluded), of which 135 (66.7%) will require retreatment.  A total sample size of 201 (which 
includes 133 subjects with the disease) achieves 99% power to reject the null hypothesis for sensitivity, 
and 85% power to reject the null hypothesis for specificity. 
 
 
8.   REFERENCES 
 
Akai H, Kiryu S, Matsuda I, et al. Detection of hepatocellular carcinoma by Gd-EOB-DTPA-enhanced liver 
MRI: comparison with triple phase 64 detector row helical CT. Eur J Radiol 2011; 80:310-5. 
 
Alterkruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival 
trends in the United States from 1975 to 2005. J Clin Oncol 2009; 27:1485-92. 
 
Barr RG. Off-label use of ultrasound contrast agents for abdominal imaging in the United States. J 
Ultrasound Med 2013; 32:7-12. 
 
Bouakaz A, de Jong N. WFUMB Safety Symposium on Echo-Contrast Agents: nature and types of 
ultrasound contrast agents. Ultrasound Med Biol 2007; 33:187-96. 
 
Bouhlel N, Coron A, Barrois G, et al. Dual-mode registration of dynamic contrast-enhanced ultrasound 
combining tissue and contrast sequences. Ultrasonics 2014; 54:1289-99. 
 
Brown DB, Nikolic B, Covey AM, et al. Quality improvement guidelines for transhepatic arterial 
chemoembolization, embolization, and chemotherapeutic infusion for hepatic malignancy. J Vasc Interv 
Radiol 2012; 23:287-94. 
 
Bruix J, Llovet JM. Prognostic prediction and treatment strategy in hepatocellular carcinoma. Hepatology 
2002; 35:520-24. 
 
Burger I, Hong K, Schulick R, et al. Transarterial chemoembolization in unresectable 
cholangiocarcinoma: initial experiences in a single institution. J Vasc Interv Radiol 2005; 16:353-61. 
Chapman WC, Majella Doyle MB, Stuart JE, et al. Outcomes of neoadjuvant transarterial 
chemoembolization to downstage hepatocellular carcinoma before liver transplantation. Ann Surg 2008; 
248:617-25. 
 

 
32 
Claudon M, Dietrich CF, Choi BI, et al. Guidelines and good clinical practice recommendations for Contrast 
Enhanced Ultrasound (CEUS) in the liver- update 2012: A WFUMB-EFSUMB initiative in cooperation 
with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol 2013; 39:187-
210. 
 
Correas JM, Bridal L, Lesavre A, et al. Ultrasound contrast agents: properties, principles of action, 
tolerance, and artifacts. Eur Radiol 2001; 11:1316-28. 
 
Dave JK, Forsberg F. Novel automated motion compensation technique for producing cumulative 
maximum intensity subharmonic images. Ultrasound Med Biol 2009; 35:1555-63. 
 
El-Serag HB, Mason AC. Rising incidence of hepatocellular carcinoma in the United States. N Engl J 
Med 1999; 340:745-50. 
 
Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer incidence and mortality 
worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on 
Cancer; 2013. Available from: http://globocan.iarc.fr, accessed on 1/5/2014. 
 
Fiorentini G, Aliberti C, Turrisi G, et al. Intraarterial hepatic chemoembolization of liver metasastases 
from colorectal cancer adopting irinotecan-eluting beads: results of a phase II clinical study. In Vivo 
2007; 21:1085-91. 
 
Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. Third Edition. 2003, John 
Wiley & Sons, New York. 
 
Gaba RC. Chemoembolization practice paterns and technical methods among intervention radiologists: 
results of an online survey. AJR Am J Roentgenol 2012; 198:692-9. 
 
Giroux MF, Braum RA, Soulen MC. Chemoembolization of liver metastasis from breast carcinoma. J 
Vasc Interv Radiol 2004; 15:289-91. 
 
Goldberg BB, Raichlen JS, Forsberg F.  Ultrasound Contrast Agents: Basic Principles and Clinical 
Applications, 2nd Ed, Martin Dunitz Ltd., London, 2001. 
 
Gonslaves CF, Brown DB. Chemoembolization of hepatic malignancy. Abdom Imaging 2009; 34:557-65. 
 
Hammerstingl R, Huppertz A, Breuer J, et al. Diangostic efficacy of gadoxetic acid (Primovist)-enhanced 
MRI and sprial CT for a therapeutic strategy: comparison with intraoperative and histopathologic findings 
in focal liver lesions. Eur Radiol 2008; 18:457-67. 
 
Herber S, Otto G, Schneider J, et al. Transarterial chemoembolization (TACE) for inoperable intrahepatic 
cholangiocarcinoma. Cariovasv Interv Radiol 2007; 30:1156-65. 
 
Imaeda T, Yamawaki Y, Seki M, et al. Lipiodol retention and massive necrosis after liodol-
chemembolization of hepatocellular carcinoma: correlation between computed tomography and 
histopathology. Cardiovasc Intervent Radiol 1993; 16:209-13. 
 
Ito K, Honjo K, Fujita T, et al. Therapeutic efficacy of transcatheter arterial chemoembolization for 
hepatocellular carcinoma: MRI and pathology. J Comput Assit Tomogr 1995; 19:198-203. 
 

 
33 
Kim WR, Stock PG, Smith JM, et al. OPTN/SRTR 2011 Annual Data Report: liver. Am J Transplant 
2013; 13:S73-102. 
 
Kono Y, Lucidarme O, Choi SH, et al. Contrast-enhanced ultrasound as a predictor of treatment efficacy 
within 2 weeks alter transarterial chemoembolization of hepatocellular carcinoma. J Vasc Interv Radiol 
2007; 18:57-65. 
 
Lammer J, Malagrari K, Vogl T, et al. Prospective randomized study of doxorubicin-eluting-bead 
embolizaion in the treatment of hepatocellular carcinoma: results of the PRECISION V study. Cardiovasc 
Intervent Radiol 2010; 33:41-52. 
 
Lewis AL, Gonzalez MV, Lloyd AW, et al. DC Bead: in Vitro characterization of a drug-delivery device 
for transarterial chemoembolization. J Vasc Interv Radiol 2006; 17:335-42. 
 
Llovet JM, Fuster J, Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular 
carcinoma: resection versus transplantation. Hepatology 1999; 39:1434-40. 
 
Llovet JM, Ducreux M, Lencioni R, et al. EASL-EORTC clinical practice guidelines: management of 
hepatocellular carcinoma. J Hepatol 2012; 56:908-43. 
 
Madoff DC, Gupta S, Ahrar K, et al. Update on the management of neuroendocrine hepatic metastases. J 
Vasc Interv Radiol 2006; 17:1235-50. 
 
Moschouris H, Malagari K, Papadaki MG, et al. Contrast-enhanced ultrasonography of hepatocellular 
carcinoma after chemoembolization using drug-eluting beads: a pilot study focused on sustained tumor 
necrosis. Cardiovasc Intervent Radiol 2010; 33:1022-1027 
 
Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. 
Statistics in Medicine 1998; 17:857-872. 
 
Patel K, Sullivan K, BerD D, et al. Chemoembolizaiton of the hepatic artery with BCNU for metastatic 
uveal melanoma: results of a Phase II study. Melanoma Res 2005; 15:297-304. 
Phillips P, Gardner E. Contrast-agent detection and quantification. Eur Radiol 2004; 14:P4-10. 
 
Salvaggio G, Campisi A, lo Greco V, et al. Evaluation of posttreatment response of hepatocellular 
carcinoma: comparison of ultrasonography with second generation ultrasound contrast agent and 
multidetector CT.  Abdom Imaging 2010; 35:447-53. 
 
Sasaki Y, Imaoko S, Kasugai H, et al. A new approach to chemoembolization therapy for hepatoma using 
ethiodized oil, cisplatin, and gelatin sponge. Cancer 1987; 60:1194-1203. 
 
Sato T, Sullivan KL, Eschelman DJ, et al. Immunoembolization of malignant liver tumor with GM-CSF 
and ethiodized oil followed by gelatin sponge pledgets. The final results of a phase I/IIa study. J Clin 
Oncol 2005; 23:16s-19s. 
 
Shaw CM, Eisenbrey JR, Lyshchik A, et al. Contrast enhanced ultrasound evaluation of residual blood 
flow to hepatocellular carcinoma after treatment with transarterial chemoembolization using drug eluting 
beads: a prospective study J Ultrasound Med. 2014; In Press. 
 
Shellock FG, Spinazzi A. MRI safety update 2008: Part 1, MRI contrast agents and nephrogenic systemic 
fibrosis. AJR Am J Roentgenol 2008; 191:1129-39. 

 
34 
Shrout PE, Fleiss JL. Interclass correlations: uses in assessing rater reliability. Psychological Bulletin 
1979; 86:420-8. 
 
Sridharan A, Eisenbrey JR, Machado P, et al. Perfusion estimation using contrast enhanced three-
dimensional subharmonic ultrasound imaging: an in vivo study. Invest Radiol 2013; 48:654-60. 
 
Sridharan, Eisenbrey JR, Machado P, et al. Three-dimensional (3D) parametric maps for visualization of 
breast lesion vasculature using subharmonic imaging. Proc. IEEE Ultrason Symp 2014; 1152-5. 
Takizawa K, Numata K, Morimoto M, et al. Use of contrast-enhanced ultrasonography with a 
perflubutane-based contrast agent performed one day after transarterial chemoembolization for the early 
assessment of residual viable hepatocellular carcinoma. Eur J Radiol 2013; 82:1471-80. 
 
Taverna G, Colombo P, Grizzi F, et al. Fractal analysis of two-dimensional vascularity in primary 
prostate cancer and surrounding non-tumoral parenchyma. Pathol Res Pract 2009; 205:438-44. 
 
Vallone P, Gallipoli A, Izzo F, et al. Local ablation procedures in primary liver tumors: Levovist US 
versus spiral CT to evaluate therapeutic results. Anticancer Red 2003; 23:5075-9. 
 
Van Ha TG. Transarterial chemoembolization for hepatocellular carcinoma. Semin Intervent Radiol 2009; 
26:270-75. 
Varela M, Real MI, Burrel M, et al. Chemoembolization of hepatocellular carcinoma with drug eluting 
beads: efficacy and doxorubicin pharmacokinetics. J Hepatol 2007; 46:474-81. 
 
Vogl TJ, Lemmer J, Lencioni R, et al. Liver, gastrointestinal, and cardiac toxicity in intermediate 
hepatocellular carcinoma treated with PRECISION TACE with drug-eluting beads: results from the 
PRECISION V randomized trial. AJR Am J Roentgenol 2011; 197:W562-570. 
 
Watt KD, Pedersen RA, Kremers WK, et al. Evolution of causes and risk factors for mortality post-liver 
transplant: results of the NIDDK long-term follow-up study. Am J Transplant 2010; 10:1420-7. 
 
Wei K, Mulvagh SL, Carson L, et al. The safety of Definity and Optison for ultrasound image enhancement: 
a retrospective analysis of 78,383 administered contrast doses. J Am Soc Echocardiogr 2008; 21:1202-6. 
 
Weiss RD, Ahmad M, Vallanueva F, et al. CaRES (Contrast echocardiography registry for safety 
surveillance): a new prospective multicenter study to evaluate the safety of the ultrasound contrast agent 
definity in clinical practice. J Am Soc Echocardiogr 2012; 25:790-5. 
 
Westwood M, Joore M, Grutters J, et al. Contrast-enhanced ultrasound using SonoVue (sulphur 
hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrast-
enhanced magnetic resonance imaging for the characterization of focal liver lesions and detection of liver 
metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 2013; 17:1-243. 
 
Yamada R, Kishi K, Sato M, et al. Transcatheter arterial chemoembolization (TACE) in the treatment of 
unresectable liver cancer. World J Surg 1995; 19:795-800. 
 
Yan FH, Zhou KR, Cheng JM, et al. Role and limitation of FMPSPGR dynamic contrast scanning in the 
follow-up of patients with hepatocellular carcinoma treated by TACE. World J Gastroenterol 2002; 
8:658-62. 

 
35 
APPENDIX A - INVESTIGATOR OBLIGATIONS 
 
 
A. 
Institutional Review Board (IRB) and Human Subjects Research Review Board (HSRRB) 
Review/Approval 
 
The protocol and informed consent for this study must be reviewed and approved by an appropriate IRB 
and HSRRB prior to enrollment of participants in the study.  It is the responsibility of the investigator to 
assure that all aspects of the ethical review are conducted in accordance with FDA Regulations 21 CFR 
Part 56.  A letter documenting the IRB and HSRRB approval which specifically identifies the 
study/protocol must be obtained by the investigator prior to initiation of the study.  Amendments to the 
protocol will be subject to the same requirements as the original protocol.  The HSRRB must review and 
approve each modification to the study prior to implementation. 
 
A progress report with a request for re-evaluation and re-approval will be submitted by the investigator to 
the IRB and HSRRB at intervals required by the IRB, and not less than annually.  
 
After completion or termination of the study, the investigator will submit a final report to the IRB. This 
report should include: deviations from the protocol, the number and types of participants evaluated, the 
number of participants who discontinued (with reasons), results of the study, if known, and all AEs, 
including deaths. 
 
 
B. 
Informed Consent 
 
Signed, written informed consent which conforms to FDA Regulation 21 CFR Part 50, must be obtained from each 
participant prior to entering the study.  Each participant will be provided a written consent form and verbal information 
in an understandable manner which describes the nature and duration of the study.  The research study coordinator or 
the investigator will conduct the informed consent interview in a private examination room.  The potential subject will 
be allowed to discuss the study with the investigator, research study coordinator, or any persons who may have 
accompanied the potential subject.  Additionally, the participant must be allowed adequate time to consider the 
potential risks and benefits associated with his participation in the study.  The research study coordinator will sign the 
informed consent as the person conducting the consent interview.   
 
 
C. 
Data Reporting and Data Forms  
 
Data reflecting participant's experiences with the study will be recorded on CRFs by the investigator.  
 
 
D. 
Records Retention 
 
All records pertaining to the conduct of the clinical study, including CRFs, informed consent forms, source 
documents, and other study documentation must be retained for seven (7) years after the end of the study. 
 
Other study documentation includes all protocols and amendments, drug supply receipt, dispensing and 
final disposition records, IRB correspondence and approvals, signed consent forms, a blank copy of study 
consent forms, Form 1572, curriculum vitae or biosketches of members of the research team including the 
medical monitor, HSRRB correspondence and approval, and Statement of Investigator forms. 
 
Source documents include all original records of observations, results, and activities necessary to 

 
36 
reconstruct and evaluate the study.  Source documents include but are not limited to laboratory reports, 
electrocardiogram tracings, X-ray films, ultrasound images, subject diaries, subject progress notes, hospital 
charts, appointment books, radiologic reports or pharmacy records, and any other records or reports of 
procedures performed during the study.  Source documents also may include copies of the CRF or sponsor 
supplied worksheets when original information is recorded directly onto these forms. 
 
Whenever possible, an original recording of an observation should be retained as the source document.  
However, a photocopy of a record is acceptable provided it is legible and is a verified copy of the original 
document. 
 
 
E. 
Deviation from the Protocol 
 
The investigator will not deviate from the protocol without prior written approval from the IRB and the 
HSRRB.  In medical emergencies, the investigator will use medical judgment and remove the participant 
from immediate hazard.  The HSRRB and the IRB will be notified regarding the type of emergency and 
course of action taken.  Any other changes to or deviations from the protocol will be made as an amendment 
to the protocol.  The amendment must be submitted for review and approval to the local IRB and the 
HSRRB for review and approval. 
 
 
F. 
Roles and Responsibilities of Study Personnel 
 
John Eisenbrey, Ph.D., Assistant Professor of Radiology, TJU will serve as Principal Investigator on this 
project.  He will be responsible for the scientific goals of the project.  Dr. Eisenbrey will oversee patient 
recruitment, informed consent, ultrasound studies, and the data entry and statistical analyses.  He will also 
supervise the data acquisition from patients.   
 
Colette Shaw, MD, Assistant Professor of Radiology, TJU is co-PI on the grant and will be responsible 
for all scientific aims within the study. She will assist with the patient recruitment at Thomas Jefferson 
University, interpret ultrasound images and advise on clinical issues.  
 
Flemming Forsberg, PhD Professor of Radiology, TJU will assist with the patient recruitment, interpret 
ultrasound images and advise on data processing issues.   
  
Jesse Civan, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, TJU, 
will assist with the patient recruitment at Thomas Jefferson University, interpret results and advise on 
clinical issues. 
 
Andrej Lyshchik, MD, PhD, Assistant Professor of Radiology, TJU will assist with the patient 
recruitment at Thomas Jefferson University, provide input during site training and scanning, interpret 
ultrasound images and advise on clinical issues. 
 
Patrick O’Kane, MD , Assistant Professor of Radiology, TJU will assist with the patient recruitment at 
Thomas Jefferson University, provide input during site training and scanning, interpret ultrasound images 
and advise on clinical issues. 
 
Amanda Smolock, MD, Assistant Professor of Radiology, TJU will assist with the patient recruitment at 
Thomas Jefferson University, provide input during site training and scanning, interpret ultrasound images 
and advise on clinical issues. 
 

 
37 
Allison Tan, MD, Assistant Professor of Radiology, TJU will assist with the patient recruitment at Thomas 
Jefferson University, provide input during site training and scanning, interpret ultrasound images and advise 
on clinical issues 
 
Yoko Kono, MD, PhD, Assistant Professor of Medicine and Radiology, UCSD will oversee all work within 
The University of California, San Diego. She will oversee patient recruitment, supervise ultrasound 
scanning, interpret ultrasound images and advise on clinical issues. 
 
Robert Mattrey, MD, Professor of Radiology, UTSW, will provide input during site training and scanning, 
interpret ultrasound images and advise on clinical issues. 
 
Steven Rose, MD, Professor of Radiology, UCSD, will provide input during site training and scanning, and 
advise on clinical issues.  
 
 
Michael Soulen, MD, Professor of Radiology, HUP, will oversee all work within The Hospital of the 
University of Pennsylvania. He will oversee patient recruitment, supervise ultrasound scanning, advise on 
clinical issues, and interpret CEUS cases. 
 
Arthur Fleischer, MD, Professor of Radiology, Vanderbilt, will interpret ultrasound images and advise on 
clinical issues. 
 
Corrine Wessner, RDMS, is a research sonographer. She will be responsible for performing the ultrasound 
examinations under the supervision of the radiologists listed as co-investigators and the PI of the study.   
 
Susan Schultz, RDMS, is a research sonographer at HUP. She will be responsible for performing the 
ultrasound examinations under the supervision of the radiologists listed as co-investigators and the PI of 
the study.   
 
Nancy Pedano, RVM will be responsible for screening, recruiting, and scheduling patients and will explain 
the study to them.  In addition, she/he will perform data entry.   
 
Cynthia Miller, RN will prepare and administer the contrast agent, record medications, and monitor the 
patients appropriately during and after the procedure.  
 
Kirsten Bradigan, RN will prepare and administer the contrast agent, record medications, and monitor the 
patients appropriately during and after the procedure.  
 
Robert Den, M.D., Assistant Professor of Radiation Oncology, will act as the medical monitor for this 
project.  
 
 
 
Signature of PI:  
 
 
 
 
 
 
 
 
John Eisenbrey, PhD 

 
38 
APPENDIX B – DEFINITY PRODUCT INSERT

 
Appendix C 
UNANTICIPATED PROBLEM REPORT FORM 
For Sub-Site Reporting 
 
Thomas Jefferson University Principal Investigator: ___________________________ 
Sub-Site Principal Investigator: ___________________________________________ 
TJU IRB Control Number/Sub-Site Identifier: ________________________________ 
 
Protocol Title: __________________________________________________________ 
______________________________________________________________________ 
 
Subject ID: _______ 
Approx. Date of Problem: ______ 
Date Aware: ____ 
Description of Problem: ________________________________________________________ 
____________________________________________________________________________ 
 
Is this Unanticipated Problem a Protocol Deviation?           
Yes 
  
No 
 
 
Did the Unanticipated Problem pose risk to subjects or others?         Yes 
 
No 
 
 
If no, have PI or Co-I sign the form. If YES, describe the risk below: 
 
Describe the Corrective Action Plan: ____________________________________________ 
__________________________________________________________________________ 
 
 
Has the problem been resolved?  
Yes 
  
No 
 
 
Does the consent or protocol require modification?  
Yes 
  
No 
 
 
 
 
___________________________________________________________________________ 
Signature of person preparing report 
 
Date 
 
 
 
Email/Phone number 
 
 
 
___________________________________________________________________________ 
Sub-site PI signature 
 
 
 
Date 
 
 
 
Email/Phone number