Safety of a Sheath Cryoprobe Bronchoscopic Transbronchial Biopsy Technique (The FROSTBITE Trial)
Phase: NA
Conditions: Lung Diseases
Sponsor: Johns Hopkins University

 
 
 
Safety of a Sheath Cryoprobe Bronchoscopic 
Transbronchial Biopsy Technique 
 
 
NCT04486560 
 
 
Document Creation Date: October 1, 2020 

page 1 of 27 
 
Safety of a Sheath Cryoprobe Bronchoscopic Transbronchial Biopsy Technique 
ACRONYM : FROSTBITE 
 
 
Principal Investigator:  Yarmus, Lonny 
 
 
 
 
Draft or Version Number: v.0.8 
01 Oct 2020 
 
 
 
 
 

page 3 of 27 
 
 
 
STATEMENT OF COMPLIANCE  
 
The trial will be conducted in accordance with the ICH GCP E6, the Code of Federal Regulations on the 
Protection of Human Subjects (45 CFR Part 46), and the STTR Terms of Award. The Principal Investigator 
will assure that no deviation from, or changes to the protocol will take place without prior agreement 
from the sponsor and documented approval from the Institutional Review Board (IRB), except where 
necessary to eliminate an immediate hazard(s) to the trial participants. All personnel involved in the 
conduct of this study have completed Human Subjects Protection Training. 
 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitments.  
Principal Investigator: ________________________________ 
Print/Type Name  
Signed: _____________________________________   Date: ______________ 
 
    Signature 
 
 

page 4 of 27 
 
STUDY CONTACT INFORMATION 
 
Coordinating Center 
 
Core Lab  
 
Johns Hopkins University 
 
Principle Investigator (Lead PI): 
 
Lonny Yarmus, DO 
Associate Professor of Medicine 
Johns Hopkins University 
Phone: 410-502-2533 
Email:  lyarmus@jhmi.edu 
 
Research Coordinator: 
 
Jenna Los 
Research Program Manager 
Phone:  410-955-5288 
Email: jlos1@jhmi.edu 
 
 
 
Pathology: 
Peter Illei, MD 
Associate Professor of Pathology 
Johns Hopkins University 
pillei1@jhmi.edu 
 
Radiology: 
Cheng Tin (Tony) Lin 
Associate Professor of Radiology 
Johns Hopkins University 
clin97@jhmi.edu 
Additional Site Contact 
 
Fabien Maldonado, MD 
Associate Professor of Medicine 
Vanderbilt University 
Phone: 615-322-3412 
Email: 
fabien.maldonado@vanderbilt.edu 
 
 
 
 
 
 

page 6 of 27 
 
PROTOCOL SYNOPSIS 
Title: 
Safety of a Sheath Cryoprobe Bronchoscopic 
Transbronchial Biopsy Technique 
 (The FROSTBITE Trial) 
Study Objective: 
To determine the safety profile of a 1.1mm 
flexible single-use cryoprobe with oversheath  
used for transbronchial lung biopsy via a 
bronchoscopic approach 
Study Device: 
ERBE 1.1mm flexible single-use cryoprobe with 
oversheath 
Design: 
A multi-center, non-randomized, single-arm, 
prospective trial designed to determine the 
safety profile of a novel cryoprobe and generate 
preliminary efficacy data. 
Phase: 
Post-Market 
Number of Sites enrolling participants: 
2 
Number of Subjects: 
50 
Study Participant Duration: 
30 days 
Study Duration: 
3 months 
Population: 
Inclusion Criteria: 
• 
Male or Female, ≥ 18-years-old 
• 
Scheduled to undergo bronchoscopy 
with transbronchial biopsy as the 
standard medical care determined by 
their treating pulmonologist 
Exclusion Criteria: 
• 
Pregnant or nursing females, or females 
of child bearing potential who refuse to 
take a pregnancy test prior to 
enrollment 
• 
Individuals with current or recent 
systematic conditions, such as 
uncontrolled hypertension (systolic > 
200 mmHg or diastolic > 110 mmHg), 
type 1 diabetes, severe pulmonary 
hypertension, acute kidney injury, stroke 
(within the last 6 months) or myocardial 
infarction (within the last 3 months) 
• 
Presence of bleeding disorder 
• 
Platelet count <50,000  
• 
Current use of systemic anticoagulation 
or antiplatelet therapy without the 
ability to hold therapy for the 
recommended amount of time prior to 
an invasive procedure (aspirin 
monotherapy is acceptable) 

page 7 of 27 
 
• 
International Normalized Ratio (INR) 
<1.5 
• 
Robotic Bronchoscopy 
• 
Do Not Resuscitate (DNR) status 
• 
Do Not Intubate (DNI) status 
 
Endpoints: 
The primary endpoint will be the number of 
serious adverse events in those enrolled in the 
study. Serious adverse events are defined as: 
• 
Grade 3 or 4 bleeding 
• 
Pneumothorax requiring chest tube 
placement (Grade ≥2) 
• 
30-day respiratory failure and death. 
 
Secondary endpoints include minor adverse 
events (bleeding Grade 1 or 2), pneumothorax 
not requiring chest tube placement (Grade 1), 
histologic accessibility, diagnostic yield 
Statistical Methodology 
This study is designed to ensure the serious 
adverse event rate using the 1.1mm flexible 
single-use cryoprobe with oversheath will not 
exceed the expected serious adverse event rate 
of transbronchial biopsy using standard biopsy 
procedures (30%) 
Safety Monitoring 
After each 10 consecutive patients are enrolled, 
the DSMB will review safety. Additionally, after 
each serious adverse event, the study will be 
halted until adjudicated by the DSMB. 
 
 
 

page 8 of 27 
 
1. BACKGROUND  
The current standard method for obtaining bronchoscopic lung biopsy specimens is transbronchial 
forceps biopsy (FBx). However, the utility and diagnostic capability of FBx is limited by poor specimen 
quality due to small biopsy size, crush artifact and cellular artifact.1 In part due to these restraints, the 
diagnostic yield of FBx has remained limited to 34-58% in diffuse lung disease1-3 and 54-58% for 
pulmonary nodules4,5. With the promise of obtaining higher quality tissue samples, cryoprobe biopsy 
(CBx) offers a similarly minimal invasive alternative to standard FBx. 
 
Cryoprobes have been used in the bronchoscopic management of malignant endobronchial disease and 
for transbronchial biopsy. The CBx operates using the Joule-Thomson effect, in which compressed gas 
undergoes adiabatic expansion and rapidly cools the probes’ tip. This allows for adequate anchoring of 
the probe to lung parenchyma and biopsy specimen retrieval. There have been numerous recent studies 
evaluating the performance of CBx. Higher diagnostic yields and larger biopsy sizes with better quality 
have been observed using CBx over FBx2,3,6-8. However, these benefits might come at a cost of higher 
complication rates, specifically, higher bleeding risks. 
1.1. STUDY RATIONALE  
One of the drawbacks of the current available CBx system (Erbe Elektromedizin GmbH) is the need for 
en bloc removal of the cryoprobe, specimen, and bronchoscope out of the patient’s airway to retrieve 
the sample. This timeframe when the scope is removed may increase bleeding complications usually 
mitigated by keeping the scope wedged after each biopsy. This necessitates a secure airway to permit 
rapid re-entry of the bronchoscope, and placement of a prophylactic bronchial blocker which limited this 
procedure to advanced bronchoscopists. To overcome this obstacle, a novel, smaller 1.1mm flexible 
single-use cryoprobe (SCBx) with oversheath has been developed that can retract the tissue sample 
through the oversheath via the working channel of the bronchoscope while the scope remains wedged 
in the airway. This permits a technically less cumbersome biopsy while the scope remains in place to 
manage potential complications. It is reasonable to hypothesize that due to these advancements in 
procedural technique, the safety profile of this new SCBx would be superior to traditional CBx. That said, 
no prospective trials have been performed evaluating the safety of the SCBx. Here, we propose the first 
human studies to evaluate the safety of the SCBx for bronchoscopic transbronchial lung biopsy. 
1.2. DEVICE DESCRIPTION  
The ERBE 1.1mm flexible single-use cryoprobe with oversheath has been approved by the US Food and 
Drug Agency (FDA) under a 510(k) application (ERBECRYO® 2 Cryosurgical Unit and Accessories - 
K190651).It is to be used with the ERBECRYO 2 unit. The ERBECRYO 2 is a device which was designed and 
optimized to address many of the clinical variables known to affect previous generations of the 
technology. This device contains an advanced flow-control system which is intended to provide 
optimized and reproducible CO2 gas flow for each individual probe specification, including the 
miniaturized 1.1mm cryoprobe. This optimized gas flow is an important variable to support 
standardization of the technical and clinical performance.  
 
The use of an oversheath with the 1.1mm single-use flexible cryoprobe enables the working channel of 
the bronchoscope to be protected during retrieval of cryobiopsy specimens. This enables retrieval of the 
biopsy specimen through the working channel of the bronchoscope in a similar fashion to transbronchial 
forceps, brush and needle biopsy, permitting the bronchoscope to remain in place while biopsy samples 
are retrieved. In this study, the 1.1mm single-use flexible cryoprobe with oversheath will be used 
according to the associated Instructions for Use (IFU).  

page 9 of 27 
 
1.3. PRIOR CLINICAL DATA 
Preliminary studies were performed in a porcine model to better evaluate the performance of SCBx.6 In 
a prospective, randomized, single blinded study, a 1.1mm SCBx probe, 1.9mm CBx probe, and standard 
2.0mm FBx forceps were compared, assessing histologic adequacy and accessibility, sample quantity and 
quality, and procedure time. Samples adequate for standard pathologic processing were retrieved with 
82.1% of the SCBx specimens, 82.9%% of the CBx specimens, and 30% of the FBx specimens. The 
histologic accessibility and biopsy area of both SCBx and CBx was superior to FBx (Figure 1 6). Procedure 
time for FBx was faster than for both SCBx and CBx, but SCBx was significantly faster than CBx (P < 
.0001). Fluoroscopy time was lower for both SCBx and CBx compared with FBx. This preliminary study 
demonstrated SCBx is a feasible technique to retrieve specimens through the working channel of a 
bronchoscope resulting in higher quality biopsy specimens compared with FBx.  
 
1.4. POTENTIAL RISKS AND BENEFITS 
This is the first-in-human dedicated post-market safety study using the new 1.1mm single-use flexible 
cryoprobe with oversheath. Prior larger reusable cryoprobes (1.9mm, 2.4mm) of the prior generation 
have been shown to be safe and efficacious. The risks of using the smaller 1.1mm single-use flexible 
cryoprobe with oversheath are similar to use of the larger probes. The risks associated with 
bronchoscopy and cryoprobe transbronchial biopsy include: 
Figure 1: Comparison of histologic accessibility and 
biopsy area between SCBx, CBx and FBx 

page 10 of 27 
 
• Alteration of vocal cords (hoarse)  
• Pharyngitis 
• Hypertension 
• Dysrhythmias 
• Bronchospasm 
• Pneumonia 
• Injury to mouth or pharynx 
• Hemoptysis 
• Injury to teeth or related soft tissues 
• Pulmonary edema 
• Chills/fever 
• Empyema 
• Laryngospasm 
• Pulmonary infiltrate 
• Coughing 
• Excessive bleeding 
• Lung parenchymal infection 
• Puncturing of the airway 
• COPD exacerbation 
• 
Thromboembolism 
• Myocardial ischemia 
• Spasm of the airway 
• Dyspnea 
 
 
 
Only trained and experienced bronchoscopists will perform the study procedure. 
Possible Risks of Participation in this Clinical Study 
There are standard risks of participating in a research study such as accidental disclosure of subject’s 
confidential information. Every effort will be made to protect the privacy of research subjects. Subject 
names and protected health information (PHI) will be kept confidential to the extent possible and as 
required by applicable laws and regulations. All records and data related to the study will be maintained 
in a secure protected space, with access restricted to study personnel only. 
 
1.5. POTENTIAL BENEFITS 
It is possible that subjects will not receive any benefits from transbronchial cryobiopsy. Subjects may 
benefit from optimized medical management of their disease. Potential benefits of the procedure may 
be increased size of the biopsy specimen, providing additional tissue for pathologic analysis. This may 
lead to increases in the diagnostic yield of the bronchoscopy. 
2. RESEARCH DESIGN AND METHODS 
This is a multi-center, non-randomized, single-arm, prospective trial designed to evaluate the safety of a 
novel 1.1mm single-use flexible cryoprobe with oversheath. Consecutive patients who have been 
referred for transbronchial biopsy by their treating pulmonologists will be enrolled. Transbronchial 
biopsy will be performed using the ERBE 1.1mm single-use flexible cryoprobe with oversheath together 
with the ERBECRYO 2 unit. 
2.1. OBJECTIVE AND PURPOSE 
The objective of this study is to evaluate the safety profile of the new 1.1mm single-use flexible 
cryoprobe with oversheath for the sampling of lung tissue. The safety profile will be assessed across the 

page 11 of 27 
 
various indications for transbronchial lung biopsy (i.e. lung transplant rejection surveillance, lung nodule 
biopsy, diffuse parenchymal lung disease, pneumonitis). Safety will be assessed by collecting AE and SAE 
information up to 30 days.  
2.2. PRIMARY SAFETY ENDPOINT 
The primary safety outcome will be the proportion of participants enrolled that underwent a device 
related Serious Adverse Events. A complication will be considered ‘device related’ if it occurs following 
the index procedure of an attempt at cryoprobe insertion into the working channel of the 
bronchoscope.  
 
A device related Serious Adverse Event is defined by the presence of any of the following: 
• 
bleeding grade ≥ 3 (see Adverse Events for bleeding grading system) 
• 
pneumothorax requiring chest tube placement (Grade ≥2, see Adverse Events for pneumothorax 
grading system) 
• 
post-procedure respiratory failure defined as the need for non-invasive or mechanical 
ventilation requiring ICU admission within 30 days after procedure 
• 
Death within 30 days after procedure 
2.3. SECONDARY ENDPOINTS  
Secondary Outcomes will include (for definitions, see Data Collection): 
1) Mild or Moderate Adverse Events: Rate of bleeding grade ≤2, pneumothorax not requiring chest 
tube placement (Grade 1) 
2) Histologic Accessibility Grade   
3) Total Histologic area (mm2) 
4) Alveolated Area (mm2) 
5) Open alveoli percent 
6) Percent crush artifact 
7) Artifact free lung parenchyma percent 
8) Activation time 
9) Diagnostic Yield: defined as proportion of patients for which the cryobiopsy sample led to a 
specific diagnosis on histologic examination 
10) Procedure time 
2.4. STUDY SITE PARTICIPATION 
This study will require a minimum of two participating sites. Each site will have a sufficient patient 
population to enroll 20-30 subjects over the enrollment period (3 months). Each site must have 
sufficient transbronchial biopsy volume (defined as at least 100 cases per year). To ensure adequate 
access to patients across the various indications for transbronchial biopsy, each site must have 
institutional centers for Lung Cancer, Lung Transplantation and Interstitial Lung Disease. In addition, the 
principal investigator and each participating co-investigator at each site must have cryobiopsy 
experience, defined as completion of at least 10 cryobiopsies. 
2.5. SUBJECT ENROLLMENT 
Patients presenting to their pulmonologist in need of a standard of care assessment of a transbronchial 
lung abnormality via bronchoscopic biopsy and who meet inclusion/exclusion criteria will be invited to 
participate. The PI will confirm subject eligibility.  
 

page 12 of 27 
 
Patients who sign the informed consent form will be considered enrolled. Patients who undergo 
bronchoscopy with at least one cryobiopsy attempt will be included within the analysis population. 
 
2.6. PARTICIPANT INCLUSION CRITERIA 
• 
Male or Female, ≥ 18-years-old 
• 
Scheduled to undergo bronchoscopy with transbronchial biopsy as the standard medical care 
determined by their treating pulmonologist 
2.7. PARTICIPANT EXCLUSION CRITERIA 
• 
Pregnant or nursing females, or females of child bearing potential who refuse to take a 
pregnancy test prior to enrollment 
• 
Individuals with current or recent systematic conditions, such as uncontrolled hypertension 
(systolic > 200 mmHg or diastolic > 110 mmHg), type 1 diabetes, severe pulmonary 
hypertension, acute kidney injury, stroke (within the last 6 months) or myocardial infarction 
(within the last 3 months) 
• 
Presence of bleeding disorder 
• 
Platelet count <50,000  
• 
Current use of systemic anticoagulation or antiplatelet therapy without the ability to hold 
therapy for the recommended amount of time prior to an invasive procedure (aspirin 
monotherapy is acceptable) 
• 
International Normalized Ratio (INR) <1.5 
• 
Robotic Bronchoscopy 
• 
Do Not Resuscitate (DNR) status 
• 
Do Not Intubate (DNI) status 
2.8. WITHDRAWAL OF SUBJECTS 
Subjects who have signed an informed consent form may be withdrawn from this study if they withdraw 
their consent, or if the investigator determines the subject should no longer continue in the study. 
Subjects may be excluded early from the study at the discretion of the investigator if continued 
participation in the trial would in some way jeopardize the subject’s health or welfare, or as a result of 
voluntary withdrawal, being lost to follow-up (LTFU), death, or other reasons not related to SAEs.  
Regardless of the reason for withdrawal, data available for the subject at the time of withdrawal, 
including the reason for withdrawal, will be entered on the Case Report Forms (CRFs). Data collected up 
to the time of withdrawal may be used by the sponsor and supporting medical device manufacturer for 
regulatory submissions, publications and other study related data analyses. In cases of withdrawal or 
LTFU, the study Investigator should document the contact attempts and reasons for subject withdrawal 
or lost to follow up with other supporting information as requested on the appropriate CRFs. 
3. STUDY PROCEDURES 
3.1. SCREENING AND INFORMED CONSENT 
Patient screening will follow each participating institution’s standard of care. A member of the Research 
Team at the site will review the subject’s previously documented standard of care medical information 
(including CT from the referring doctor) for eligibility and inclusion into the study. Subjects will be 
approached to obtain informed consent prior to any study-specific procedure.  Informed consent will 
take place in a private environment (e.g. patient exam room), free from distractions. The PI or study 

page 13 of 27 
 
team member will approach the subject at their standard of care clinic appointment or prior to their 
scheduled bronchoscopy and will explain the study to qualified subjects prior to obtaining consent. All 
individuals who obtain consent (PI, Sub-investigators, and study coordinators) must have completion 
certificates for the CITI Human Subjects Research Education Course. Interviews to obtain consent will 
not follow any stressful situation (e.g. patient being informed he/she may have cancer) and will not be 
conducted if the patient has received any mind-altering medications or anesthesia. Patients will be 
assessed for their capacity to consent by the ability to show comprehension of the procedure, ask 
appropriate questions, and appear properly oriented. A signed copy of all consents and the HIPAA 
authorization document will also be given to consenting subjects. 
 
3.2. SCREEN FAILURES 
Subjects who provide informed consent, but are determined to be ineligible prior to the index 
procedure (insertion of the cryoprobe into the working channel of the bronchoscope) will be considered 
screen failures.  The reason for screen failure will be documented. 
 
3.3. SEDATION/AIRWAY 
Patients will undergo the procedure under deep sedation with an artificial airway (endotracheal tube, 
laryngeal mask airway or tracheostomy) in place. The use of a rigid bronchoscope will be left to the 
discretion of the physician performing the procedure. Deep sedation medications and route of 
administration are at the discretion of the sedating physician.  
 
3.4. BRONCHOSCOPIC BIOPSY 
Prior to induction of anesthesia, the 1.1mm flexible single-use cryoprobe will be connected to the 
ERBECRYO 2 unit via the plug (see IFU for full details). The cryoprobe should be tested as described in 
the instruction for use (IFU) by immersing the cryotip to a depth of at least 5 cm in sterile warm water at 
a temperature of approx. 20°C (68°F) and by activating the freeze function of the ERBECRYO 2 for 
approximately 5 seconds. A clearly visible, homogenous ball of ice must form at the cryotip when 
freezing capacity is sufficient. Gas bubbles must not escape under any circumstances. Once tested, 
induction of anesthesia may be performed.  
 
Once appropriate sedation has been achieved and a secure airway has been placed, an airway 
inspection is to be performed. Following airway inspection and after the appropriate airway has been 
selected, the cryoprobe multiadapter will be secured to the working channel connector of the 
bronchoscope. The oversheath can then be inserted and secured to the multiadapter. The cryoprobe 
can then be inserted through the oversheath via the bronchoscope into the targeted airway using tactile 
control until in the targeted location is reached. It is optional to place a deflated prophylactic bronchial 
blocker prior to biopsy. The freeze function is then activated. The initial freeze time will be 4 seconds as 
measured on the device timer. At the discretion of the bronchoscopist, should inadequate tissue be 
collected due to incomplete freeze, the freeze time can be extended by 1 second on each consecutive 
attempt, up to a maximum of 8 seconds. The cryoprobe along with the biopsy specimen is removed with 
a jerk motion analogous to the same motion used for standard forceps.  The sample is then extracted 
through the oversheath with the bronchoscope remaining in the airway, thereby maintaining freezing 
activation until the specimen is completely out of the bronchoscope.  It is important, that the specimen 
is pulled quickly into the oversheath with the first movement as far as possible in order to squeeze soft 
tissue in the oversheath. The freeze function is then deactivated and the specimen should immediately 

page 14 of 27 
 
be placed in saline. The removal tool accompanying each cryoprobe can be used to carefully remove the 
specimen from the tip of the cryoprobe only after the specimen was defrosted. Specimens will then be 
transferred into a fixative (i.e. formalin) per institutional policy and sent to the local institutional 
pathology lab for processing and interpretation. Each biopsy sample will then be sent for central 
pathology interpretation. If tissue cultures are clinically indicated, an additional specimen may be placed 
in sterile saline 
For non-lung transplant rejection related biopsies, a minimum of 3 biopsies must be taken using the 
1.1mm sheath cryoprobe. For lung transplant rejection surveillance biopsies, a minimum of 5 
cryobiopsies must be taken (more if needed), as per IHSLT guidelines, at least 5 pieces of well-expanded 
alveolated lung parenchyma are required for an assessment of acute rejection.9 As part of this study, 
only cryobiopsy with the 1.1mm single-use flexible cryoprobe with oversheath is permitted for 
transbronchial lung biopsy. This excludes the use of needle, forceps, and brush biopsy. In case of 
cryoprobe failure a new 1.1mm sheath cryoprobe should be used. A bronchoalveolar lavage or wash is 
allowed if clinically indicated but must be performed after the index procedure is performed. 
Following the procedure, the patient will be returned to the post-anesthesia care unit and a post-
procedural chest x-ray will be obtained and results will be documented.  
3.5. COMBINED LOCALIZATION PROCEDURES 
It is expected (in fact encouraged) that additional localization modalities in additional to standard optical 
bronchoscopy will be used in combination with the cryobiopsy as would be done with traditional biopsy 
techniques under standard of care. These include, but are not limited to, fluoroscopy, radial 
endobronchial ultrasound, and electromagnetic navigation. Robotic Bronchoscopy is excluded due to 
the fact that a standard flexible bronchoscope is not used. That said, as part of this trial, for tissue 
acquisition, the only biopsy tool permitted to be used is the cryoprobe. If convex EBUS with rapid onsite 
pathologic examination (ROSE) is being performed as part of the planned bronchoscopy, this should be 
performed prior to transbronchial cryobiopsy.  
3.6. DATA COLLECTION 
Collected data include: radiographic characteristics, procedural characteristics, diagnostic yield, and 
adverse events, as follows: 
 
Radiographic Characteristics: 
If a target location is present (i.e. biopsy for lung nodule), the location of the target lesion (side, lobe 
and segment, i.e. right upper lobe anterior segment, etc.) will be determined and recorded. The 
radiographic information collected will include size of the lesion (longest axis), distance from a 
visible bronchus, and distance from the pleural surface perpendicular to the lesion on axial cuts. If 
the patient has undergone a PET scan, the metabolic activity (measured SUV) will be recorded. 
 
If target lesions exists, to assess centrality, we will utilize proprietary software to map zones of the 
lung to determine if a lesion falls into the outer, middle, or central 1/3 of the lung parenchyma. “CT 
Pulmo 3D” workflow using Siemens Syngo via software automatically analyzes the lung parenchyma 
and define the contours of both lungs (Figure 1).  This will be performed by the core radiology 
laboratory at Johns Hopkins.  External sites to Johns Hopkins (Vanderbilt University) will submit the 
de-identified CT scan via a secure program (Ambra) that is in clinical use for secure image sharing. 

page 15 of 27 
 
 
 
Figure 2: CT Pulmo 3D software output defining central, middle and peripheral lung zones10 
 
 
For diffuse lung disease, the CT characteristic pattern will be recorded (i.e. UIP, NSIP, cystic, reticular 
nodular). Additionally, localization and distribution of infiltrates will be collected. If no specific lung 
abnormalities are noted on CT (i.e. lung transplant surveillance), this will be recorded. 
 
 
Procedural Characteristics: 
Collected procedural information will include the number of biopsy attempts, freeze time for each 
biopsy, procedural time (scope in to scope out) and use of prophylactic bronchial blocker. The type 
(general or moderate) of sedation administered as well as artificial airway selection (ETT, LMA, rigid 
bronchoscopy) will also be recorded. Room temperature and gas pressure, number of probes used. 
 
• 
Pathology Core Lab Assessment: 
An independent pathology core lab will review all study cases. The core lab will be graded on a 
previously validated histologic accessibility on a 7-point Likert Scale6,11 as follows: 
• 
Grade 0: The specimen does not contain alveolar structures and can therefore not be 
assessed as transbronchial biopsy specimen 
• 
Grade 1:  Due to very poor specimen quality, it is not possible to assess the relevant 
morphologic and histologic features 
• 
Grade 2:  Due to poor specimen quality, assessment of relevant morphologic and histologic 
structures and features is severely compromised and not possible 
• 
Grade 3: Despite high limitations in specimen quality, assessment of the relevant 
morphologic and histologic structures and features is severely compromised but possible 
• 
Grade 4: Despite moderate limitations in specimen quality, assessment of the relevant 
morphologic and histologic structures and features is compromised but possible 
• 
Grade 5: Despite low limitations in specimen quality, assessment of the relevant 
morphologic and histologic structures and features are compromised but possible 

page 16 of 27 
 
• 
Grade 6: The specimen allows for complete and unrestricted assessment of all relevant 
morphologic and histologic structures and features 
 
Additionally, the pathologic core lab will determine, the total histologic area (mm2), alveolated area 
(mm2), open alveoli percent, percent crush artifact, and artifact free lung parenchyma percent. The 
underlying diagnosis will be confirmed or rebutted. 
 
 
Diagnostic Yield: 
Diagnostic yield is defined as proportion of patients for which cryobiopsy led to a diagnosis. 
Diagnostic yield will be determined from the results of cryobiopsy specimen only. A biopsy that 
results in a specific diagnosis, either malignant or benign (granuloma, inflammation, fibrosis, 
infection) will be assumed to be a true positive.  Atypia, minimal inflammation or lung parenchyma 
without pathologic findings on final pathology reads are considered non-diagnostic.  
 
 
Room Temperature and Gas Pressure: 
 
The room temperature of the OR (by a thermometer fixed to the ERBECRYO 2 unit) and the gas 
pressure which is displayed on the cryo unit will be collected prior to the index procedure. This 
ensures standardized results throughout the study. The gas pressure and the room temperature 
must be at least 56bar and 68°F (20°C), respectively.  
3.7. Adverse Events and Serious Adverse Events 
3.7.1. Adverse Events 
An adverse event (AE) is any untoward medical occurrence, unintended disease or injury, or untoward 
clinical signs (including abnormal laboratory findings) in subjects, users or other persons, whether or not 
related to the investigational medical device.  Note:  Pre-existing conditions are not considered to be 
adverse events unless there is a change in the nature or severity of the condition. 
3.7.2. Serious Adverse Event  
A serious adverse event (SAE) is an event that has: 
1) Led to death, 
2) Led to serious deterioration in the health of the subject, that either resulted in  
a) a life-threatening illness or injury, or 
b) a permanent impairment of a body structure, or 
c) in-patient or prolonged hospitalization, or 
d) medical or surgical intervention to prevent life-threatening illness or injury or permanent 
impairment to a body structure or a body function, 
3) led to fetal distress, fetal death or a congenital abnormality or birth defect 
 
Note: Planned hospitalization for a pre-existing condition, or a procedure required by the study, without 
serious health deterioration is not considered a SAE.  
3.7.3. Adverse Event Relationship  
The PI will assess the relationship of an adverse event to the device and/or procedure as follows: 
 
Not Related:  No relationship appears to exist between the AE and the device and/or procedure 
 
Related:  The AE follows a plausible temporal sequence following administration of the study device 
or execution of the procedure. 

page 17 of 27 
 
 
Undetermined:  It is not possible to determine the relationship of the AE with the study treatment. 
3.7.4. Adverse Event Outcome 
The outcome of AEs will be recorded as follows: 
 
Resolved: The event is considered fully resolved. 
 
Continuing: At study exit the event is considered ongoing.  Note: Any unresolved AE ongoing past 
study exit will be monitored by the physician per institutional standard of care. 
3.7.5. Adverse Event Recording 
AEs will be documented in the applicable source documentation (i.e. medical record).  As possible, study 
data collection forms should capture the event diagnosis as opposed to symptoms (e.g. Infection vs. 
fever).  The adverse events of pneumothorax and bronchopulmonary hemorrhage (including 
hemoptysis) will be documented as follows: 
 
Pneumothorax:  Pneumothorax will be documented by both post-biopsy CXR and chest ultrasonography.  
Pneumothorax severity and required intervention, such as chest tube placement, will be recorded.  
Severity will be classified according to Common Terminology Criteria for Adverse Events (CTCAE) grade 
as follows: 
 
Grade 1:  Asymptomatic; clinical or diagnostic observation only; intervention not indicated 
 
Grade 2:  Symptomatic; intervention indicated (e.g. tube placement without sclerosis) 
 
Grade 3:  Sclerosis and/or operative intervention indicated; hospitalization indicated. 
 
Grade 4:  Life-threatening consequences; urgent intervention indicated 
 
Grade 5:  Death 
 
Bleeding:  Bleeding will be categorized on an adapted grading system.12 The grades are as follows:  
• 
Grade 0: No bleeding or only traces of blood not requiring suctioning 
• 
Grade 1: Bleeding requiring suction to clear 
• 
Grade 2: Bleeding requiring wedging of the biopsied segment with the flexible bronchoscope 
and/or iced saline 
• 
Grade 3: Bleeding requiring inflation of a bronchial blocker 
• 
Grade 4: Bleeding causing cardiopulmonary instability 
 
3.7.6. SERIOUS ADVERSE EVENT REPORTING 
 
A Serious Adverse Event is defined as the occurrence of bleeding grade ≥ 3 (see Adverse Events for 
bleeding grading system), pneumothorax requiring chest tube placement (Grade ≥2, see Adverse Events 
for pneumothorax grading system), post-procedure respiratory failure defined as the need for non-
invasive or mechanical ventilation requiring ICU admission, or death, which have occurred within 30 
days after procedure, respectively.  
 
All device and/or procedure related adverse events will be reported. Device related events will be 
collected from initiation of the index procedure (insertion of the cryoprobe into the working channel of 
the bronchoscope), intra-procedure, and during the standard of care follow-up period of  30 days. 30 
day follow up will be assessed by chart review, if data is not able to extracted by chart review a phone 
call will be made to assess any adverse events that may have occurred. Study sites are responsible to 
report adverse events and complications to their IRBs according to institutional requirements. 
 

page 18 of 27 
 
The study clinician at the site will complete a SAE Form within the following timelines:  
• 
All deaths and immediately life-threatening events, related to the device or the procedure will 
be recorded on the SAE Form and submitted to the DSMB/study sponsor, lead coordinating 
center, and device manufacturer within 24 hours of site awareness.  
• 
Other SAEs will be submitted to the DSMB/study sponsor and lead coordinating center within 72 
hours of site awareness.  
 
All SAEs will be followed until satisfactory resolution or until the site investigator deems the event to be 
chronic or the adherence to be stable. Other supporting documentation of the event may be requested 
by the DSMB/study sponsor and should be provided as soon as possible. The study sponsor will be 
responsible for notifying FDA of any unexpected fatal or life-threatening suspected adverse reaction as 
soon as possible but in no case later than 7 calendar days after the sponsor's initial receipt of the 
information. 
 
3.8. SAFETY OVERSIGHT 
Safety oversight will be under the direction of a DSMB composed of individuals with the appropriate 
expertise, including interventional pulmonology. Out of an abundance of caution, the DSMB will meet to 
review cases and assess safety after each 10 consecutive patients have been enrolled (cases will be 
consecutively batched in groups of 10). The DMSB will operate under the rules of an approved charter 
that will be written and reviewed at the organizational meeting of the DSMB. At this time, each data 
element that the DSMB needs to assess will be clearly defined.  
 
Proposed DSMB members: 
 
Gerard Silvestri, MD: DSMB Chair, Pulmonary and Critical Care, Medical University of South Carolina 
Momen Wahidi, MD: Interventional Pulmonary, Duke University 
Nadia Hansel, MD, Division Chief, Pulmonary and Critical Care, Johns Hopkins University 
Roy Semaan, MD, Interventional Pulmonary, University of Pittsburgh 
Anil Vachani, MD, Pulmonary and Critical Care, University of Pennsylvania 
3.9. STUDY HALTING RULES 
Any SAE will serve as a stopping rule. The DSMB will convene to adjudicate the event. Enrollment will 
resume if the SAE is adjudicated by the DSMB. Additionally, if the SAE rate rises above 30% for two 
consecutive batches (10 cases per batch), the study will be halted. 
4. CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of human subjects are 
protected, that the reported trial data are accurate, complete, and verifiable, and that the conduct of 
the trial is in compliance with the currently approved protocol/amendment(s), with GCP, and with 
applicable regulatory requirement(s).  
• 
Monitoring for this study will be performed by Johns Hopkins University  
• 
Centralized, initial assessments and monthly assessments, and comprehensive review of all 
primary and secondary endpoint data. 

page 19 of 27 
 
• 
Details of clinical site monitoring are documented in a CMP. The CMP describes in detail who 
will conduct the monitoring, at what frequency monitoring will be done, at what level of detail 
monitoring will be performed, and the distribution of monitoring reports.  
• 
Independent audits will be conducted by Johns Hopkins University to ensure monitoring 
practices are performed consistently across all participating sites and that monitors are 
following the CMP. 
5. STATISTICAL CONSIDERATIONS 
5.1. STATISTICAL AND ANALYTICAL PLANS 
The study is not powered to make a statistical conclusion due to the small sample size and the safety 
phase in which the treatment is. As the true safety profile of the 1.1mm flexible single-use cryoprobe 
with oversheath is not known, we will base our statistical plan based on current standard method for 
transbronchial biopsy, forceps biopsy. 
5.2. STATISTICAL HYPOTHESES 
1. To determine the serious adverse event rate of a 1.1mm flexible single-use cryoprobe with 
oversheath for transbronchial bronchoscopic biopsy.  
 
We hypothesize that the serious adverse event proportion using the novel smaller, 1.1mm 
flexible single-use cryoprobe with oversheath will not exceed 30%, the adverse event proportion 
for the current standard method of transbronchial biopsy using forceps. 
 
2. To determine baseline performance characteristics for the use of the 1.1mm flexible single-use 
cryoprobe with oversheath. 
 
We hypothesize that data generated during the performance of this safety trial will generate 
meaningful descriptive statistics for pathologic evaluation (histologic adequacy), procedural 
characteristics (activation time, number of biopsies taken, type of airway used), and diagnostic 
yield across various disease states necessitating transbronchial biopsy. This descriptive data will 
be crucial in the planning of future clinical trials. 
 
5.3. ANALYSIS DATASETS 
All analyses will be done using intention-to-treat analyses to properly identify safety and 
baseline performance characteristics. As participants will not be randomized, the index action 
for inclusion will be insertion of the cryoprobe into the working channel of the bronchoscope.  
5.4. DESCRIPTION OF STATISTICAL METHODS 
5.4.1. GENERAL APPROACH 
This is a multi-centered, prospective, single arm trial aimed at establishing the safety profile of a novel 
1.1mm flexible single-use cryoprobe with oversheath. Secondary outcomes will be descriptive 
procedural characteristics that will be used to power future trials. 
 
All continuous data will be presented as means with standard deviations. Categorical data will be 
represented by percentages. Statistical comparisons will be made using linear and logistic regression 

page 20 of 27 
 
analysis where applicable. Sensitivity, specificity, positive and negative predictive value and accuracy of 
all procedures will be calculated.  
 
5.4.2. ANALYSIS OF THE PRIMARY SAFETY ENDPOINT 
The primary endpoint is the incidence of serious adverse events defined as occurrence of bleeding grade 
≥ 3 (see Adverse Events for bleeding grading system), pneumothorax requiring chest tube placement 
(Grade ≥2, see Adverse Events for pneumothorax grading system), post-procedure respiratory failure 
defined as the need for non-invasive or mechanical ventilation requiring ICU admission, or death, which 
have occurred within 30 days after procedure, respectively. The incidence will be calculated as the 
proportion of patients in whom a serious adverse event occurred divided by those who underwent the 
index procedure (insertion of the cryoprobe into the working channel of the bronchoscope).  
 
As the true safety profile of the 1.1mm flexible cryoprobe with oversheath is not currently known, and 
no standard minimally significant difference in a combined bleeding and pneumothorax outcome (such 
as in this study) is known, we will use currently available literature on a comparable biopsy method, 
(forceps biopsy and the larger 1.9mm and 2.4mm cryoprobes). 
 
Based on review of the published literature (Table 1), we conservatively estimate the current combined 
bleeding and pneumothorax proportion to be 30% for transbronchial biopsy in standard practice. The 
procedure will be considered safe if the final proportion of serious adverse events is 30% or less. This 
will infer a standard of safety for the 1.1mm flexible single-use cryoprobe with oversheath comparable 
to current transbronchial biopsy standard of care. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

page 21 of 27 
 
Table 1: Literature review of bleeding and pneumothorax rates 
Author 
Definition of bleeding as per study 
Number of 
patients in 
CBx, n (%) 
Number of 
patients in 
FBx, n (%) 
Aktas et al. (2010)13, 
(n = 41); All performed CB 
and FB; CB = 41, FB = 41 
No bleeding 
26 (63.4) 
27 (65.9) 
Simultaneous bleeding 
5 (12.2) 
5 (12.2) 
Mild: cold water + adrenaline 
8 (19.5) 
9 (21.9) 
Moderate: APC application 
2 (4.9) 
0 (0) 
Severe : hemodynamic compromise 
0 (0) 
0 (0) 
Pneumothorax 
not reported 
not reported 
 
 
 
 
Hetzel et al. (2012)14, 
(n = 593); CB = 296, FB = 297 
No bleeding 
59 (19.9) 
91 (30.6) 
Mild: suctioning 
183 (61.8) 
153 (51.5) 
Severe: ice cold saline, diluted 
vasoconstrictive drug, balloon 
tamponade, APC, MV, conversion to 
rigid bronchoscope. 
54 (18.2) 
53 (17.8) 
Pneumothorax 
not reported 
not reported 
 
 
 
 
Pajares et al. (2014)3, 
(n = 77) ; CB = 39, FB = 38 
Grade 0: no bleeding 
5 (12.8) 
8 (21.1) 
Grade 1: suction 
12 (30.8) 
17 (44.7) 
Grade 2: occlusion, use of endoscopic 
procedures and/or ice cold saline 
22 (56.4) 
13 (34.2) 
Grade 3: hemodynamic compromise, 
admission to ICU 
0 (0) 
0 (0) 
Pneumothorax 
3 (7.7) 
2 (5.2) 
 
Fruchter et al. (2014)15, 
(n=75) CB single arm 
No bleeding 
70 (93) 
NA 
Significant bleeding 
3 (4) 
Pneumothorax 
2 (2.6) 
 
Hagmeyer et al. (2016)16, 
(n=32) CBx only 
No or mild bleeding  
NA 
Moderate: wedge of bronchoscope 
8 (25) 
severe: use of bronchial blocker or blood 
transfusion 
17 (53) 
Pneumothorax 
6 (19) 
NA 

page 22 of 27 
 
 
 
5.4.3. ANALYSIS OF THE SECONDARY ENDPOINTS(S) 
1. Description of histologic performance. The mean histologic adequacy score, total histologic area 
(mm2), alveolated area (mm2), open alveoli percent, percent crush artifact, and artifact free lung 
parenchyma percent will be reported as mean (+/- SD) or Median (Range). This data will be used 
for statistical planning for future trials. 
2. Procedural characteristics such as activation time, procedure time, number of biopsies taken and 
type of airway (proportion used LMA, ETT, rigid bronchoscope) used will be reported as mean (+/- 
SD) or Median (Range). Logistic regression will be used to determine if procedural characteristic 
significantly affect the presence of a significant adverse event (primary outcome). Additionally, 
linear regression will be used to determine if any of the procedural characteristics effect histologic 
performance characteristics.  
3. Diagnostic yield of cryobiopsy will be calculated as the proportion of patients for which cryobiopsy 
led to a specific diagnosis. A biopsy will be considered diagnostic, if it results in a specific 
diagnosis, either malignant or benign (granuloma, inflammation, fibrosis, infection) will be 
assumed to be a true positive.   
5.5. PLANNED INTERIM ANALYSES 
Out of an abundance of caution for safety, following each 10 consecutively completed cases, the serious 
adverse event rate will be calculated. This data will only be available to the DSMB for review. 
5.6. SAFETY REVIEW 
After any serious adverse event, a safety review will take place and recruitment at all sites will be halted. 
The DSMB will meet to review the case and overall safety of the trial, once adjudicated by the DSMB, 
the trial can be resumed. 
5.7. SAMPLE SIZE 
This is a safety study. The goal of this study is to identify any high frequency adverse events, as well as 
collect preliminary data on the potential efficacy of the novel 1.1mm flexible single-use cryoprobe with 
oversheath. As no current data exists to accurately estimate the variance in SAE rates, there is no 
reliable data to power this study. We conservatively estimate that a stable estimation will of the SAE 
rate will occur after 50 cases. Thus in this initial study, we will include 50 participants. 
6. MEASURES TO MINIMIZE BIAS: ENROLLMENT/RANDOMIZATION/MASKING PROCEDURES 
Participants will be enrolled at each institution participating in the study on a referral basis to 
interventional pulmonology. Due to the nature of the study, patients and bronchoscopists will not be 
blinded. The treating bronchoscopist will be the outcome assessor. 
7. SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS 
Both PI’s (Fabien Maldonado and Lonny Yarmus), as well as supporting manufacturer (Erbe 
Elektromedizin GmbH, Germany) will have access to de-identified study data. The site-specific 
investigators will have access to the source data available for their site only. Patients will be informed in 
the informed consent that their de-identified data will be accessible to third parties (monitors, industrial 
funder). 

page 23 of 27 
 
8. QUALITY ASSURANCE AND QUALITY CONTROL 
QC procedures will be implemented at both sites beginning with the data entry system and data QC 
checks that will be run on the database by the lead coordinating center will be generated. Any missing 
data or data anomalies will be communicated to the site(s) for clarification/resolution.  
Following written SOPs, the monitors will verify that the clinical trial is conducted and data are 
generated, documented (recorded), and reported in compliance with the protocol, GCP, and the 
applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good Manufacturing 
Practices (GMP)).  
The investigational site will provide direct access to all trial related sites, source data/documents, and 
reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities. 
9. ETHICS/PROTECTION OF HUMAN SUBJECTS 
9.1. ETHICAL STANDARD 
The principal investigator(s) will ensure that this study is conducted in full conformity with Regulations 
for the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 
56, and/or the ICH GCP E6. 
 
9.2. INSTITUTIONAL REVIEW BOARD 
The protocol, informed consent form(s), recruitment materials, and all participant materials – which will 
be consistent across both sites, except where the use of specific institutional templates is required-will 
be submitted to the site’s local IRB for review and approval. Approval of both the protocol and the 
consent form must be obtained before any participant is enrolled at the clinical site. Any amendment to 
the protocol will be communicated to all sites by the lead coordinating center and will require review 
and approval by the local IRB before the changes are implemented to the study. All changes to the 
consent form will be approved by each site’s local IRB; a determination will be made regarding whether 
previously consented participants need to be re-consented.  Direct and frequent communication via 
email and phone with Vanderbilt’s PI and research team will be maintained to ensure that both sites are 
using the most current version of the protocol and consent. 
 
10. INFORMED CONSENT PROCESS 
10.1. 
CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
Before undergoing the study procedure, the subject or his legal representative must give written 
consent to participate in the study using the ICF approved by the clinical site’s IRB, and all applicable 
signatures and dates must be obtained.  
The background of the therapy and study, the reason for the study, possible benefits, and any inherent 
risks shall be carefully explained to the subject.  The subject will be given adequate time to review, 
discuss with physician, discuss with others and to have questions answered prior to signing the IRB 
approved consent form.  

page 24 of 27 
 
A copy of the signed consent form shall be given to the subject, an original shall be filed in the subject’s 
medical record, and a copy maintained with the site’s research documentation.  
10.2. 
CONSENT PROCEDURES AND DOCUMENTATION 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation. Extensive discussion of risks and 
possible benefits of participation will be provided to the participants and their families. Consent forms 
will be IRB-approved and the participant will be asked to read and review the document. The 
investigator will explain the research study to the participant and answer any questions that may arise. 
All participants will receive a verbal explanation in terms suited to their comprehension of the purposes, 
procedures, and potential risks of the study and of their rights as research participants. Participants will 
have the opportunity to carefully review the written consent form and ask questions prior to signing. 
The participants should have the opportunity to discuss the study with their surrogates or think about it 
prior to agreeing to participate. The participant will sign the informed consent document prior to any 
procedures being done specifically for the study. The participants may withdraw consent at any time 
throughout the course of the trial. A copy of the informed consent document will be given to the 
participants for their records. The rights and welfare of the participants will be protected by 
emphasizing to them that the quality of their medical care will not be adversely affected if they decline 
to participate in this study. 
 
10.3. 
PARTICIPANT AND DATA CONFIDENTIALITY 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and the 
sponsor(s) and their agents as well as the supporting manufacturer. This confidentiality is extended to 
cover testing of biological samples in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be held in 
strict confidence. No information concerning the study or the data will be released to any unauthorized 
third party without prior written approval of the sponsor. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB or 
supporting manufacturer supplying study product may inspect all documents and records required to be 
maintained by the investigator, including but not limited to, medical records (office, clinic, or hospital) 
and pharmacy records for the participants in this study. The clinical study site will permit access to such 
records.  
The study participant’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location for 
as long a period as dictated by local IRB and Institutional regulations.  
Study participant research data, which is for purposes of statistical analysis and scientific reporting, 
will be transmitted to and stored at the Johns Hopkins Hospital. This will not include the participant’s 
contact or identifying information. Rather, individual participants and their research data will be 
identified by a unique study identification number. The study data entry and study management 
systems used by clinical sites and by the Johns Hopkins Hospital research staff will be secured and 
password protected. At the end of the study, all study databases will be de-identified and archived at 
the Johns Hopkins Hospital. 

page 25 of 27 
 
10.4. 
RESEARCH USE OF STORED HUMAN SAMPLES, SPECIMENS OR DATA 
There will be no stored human samples or specimens in this study except the taken biopsy specimens. 
Data collected for this study will be analyzed and stored at the Johns Hopkins Hospital. After the study is 
completed, the de-identified, archived data will be transmitted to and stored at the Johns Hopkins 
Hospital, under the supervision of Lonny Yarmus, for use by other researchers including those outside of 
the study. Permission to transmit data to the Johns Hopkins Hospital will be included in the informed 
consent. 
11. DATA HANDLING AND RECORD KEEPING 
11.1. 
DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
Data collection is the responsibility of the clinical trial staff at each site under the supervision of the 
site PI. The investigator at each site is responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported.  
All source documents should be completed in a neat, legible manner to ensure accurate interpretation 
of data. Black ink is required to ensure clarity of reproduced copies. When making changes or 
corrections, cross out the original entry with a single line, and initial and date the change. Do not erase, 
overwrite, or use correction fluid or tape on the original. 
 
Copies of the electronic CRF (eCRF) will be provided for use as source documents and maintained for 
recording data for each participant enrolled in the study. Data reported in the eCRF derived from source 
documents should be consistent with the source documents or the discrepancies should be explained 
and captured in a progress note and maintained in the participant’s official electronic study record.   All 
sites will communicate any discrepancies to the lead coordinating center, sponsor, and DSMB which will 
also have access to the de-identified electronic study records on REDCap. 
Clinical data (including AEs, concomitant medications, and expected adverse reactions data) and clinical 
laboratory data will be entered into REDCap, a 21 CFR Part 11-compliant data capture system provided 
by the Johns Hopkins Hospital. The data system includes password protection and internal quality 
checks, such as automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate. Clinical data will be entered directly from the source documents by research staff at each 
site.   
 
11.2. 
PROTOCOL DEVIATIONS 
A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or MOP requirements. 
The noncompliance may be either on the part of the participant, the investigator, or the study site staff. 
As a result of deviations, corrective actions are to be developed by the site and implemented promptly. 
These practices are consistent with ICH E6:  
• 
Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of each site to use continuous vigilance to identify and report deviations to the 
local IRB, the lead coordinating center, the sponsor, and the DSMB within 5 working days of 
identification of the protocol deviation, or within 5 working days of the scheduled protocol-required 
activity. Protocol deviations must be sent to the local IRB per their guidelines. The site PI/study staff is 

page 26 of 27 
 
responsible for knowing and adhering to their IRB requirements. 
 
11.3. 
PUBLICATION AND DATA SHARING POLICY 
The International Committee of Medical Journal Editors (ICMJE) member journals have adopted a 
clinical trials registration policy as a condition for publication. The ICMJE defines a clinical trial as any 
research project that prospectively assigns human subjects to intervention or concurrent comparison or 
control groups to study the cause-and-effect relationship between a medical intervention and a health 
outcome. Medical interventions include drugs, surgical procedures, devices, behavioral treatments, 
process-of-care changes, and the like. Health outcomes include any biomedical or health-related 
measures obtained in patients or participants, including pharmacokinetic measures and adverse events. 
The ICMJE policy, and the Section 801 of the Food and Drug Administration Amendments Act of 2007, 
requires that all clinical trials be registered in a public trials registry such as ClinicalTrials.gov, which is 
sponsored by the National Library of Medicine. Other biomedical journals are considering adopting 
similar policies. For interventional clinical trials performed under NIH IC grants and cooperative 
agreements, it is the grantee’s responsibility to register the trial in an acceptable registry, so the 
research results may be considered for publication in ICMJE member journals. The ICMJE does not 
review specific studies to determine whether registration is necessary; instead, the committee 
recommends that researchers who have questions about the need to register on the side of registration 
or consult the editorial office of the journal in which they wish to publish.  
FDAAA mandates that a "responsible party" (i.e., the sponsor or designated principal investigator) 
register and report results of certain "applicable clinical trials":  
• 
Trials of Drugs and Biologics: Controlled, clinical investigations, other than Phase I investigations, 
of a product subject to FDA regulation; 
• 
Trials of Devices: Controlled trials with health outcomes of a product subject to FDA regulation 
(other than small feasibility studies) and pediatric post-market surveillance studies. 
 
12. CONFLICT OF INTERESTS POLICY 
The independence of this study from any actual or perceived influence, such as by medical device 
industry, is critical. Therefore any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a 
way that is appropriate to their participation in the trial. The study leadership has established policies 
and procedures for all study group members to disclose all conflicts of interest and will establish a 
mechanism for the management of all reported dualities of interest. 
13. LITERATURE REFERENCES 
1. 
Pourabdollah M, Shamaei M, Karimi S, Karimi M, Kiani A, Jabbari HR. Transbronchial lung biopsy: 
the pathologist's point of view. The clinical respiratory journal 2016;10:211-6. 
2. 
Babiak A, Hetzel J, Krishna G, et al. Transbronchial cryobiopsy: a new tool for lung biopsies. 
Respiration 2009;78:203-8. 
3. 
Pajares V, Puzo C, Castillo D, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial 
lung disease: a randomized trial. Respirology (Carlton, Vic) 2014;19:900-6. 

page 27 of 27 
 
4. 
Ost DE, Ernst A, Lei X, et al. Diagnostic Yield and Complications of Bronchoscopy for Peripheral 
Lung Lesions. Results of the AQuIRE Registry. American Journal of Respiratory and Critical Care Medicine 
2016;193:68-77. 
5. 
Chechani V. Bronchoscopic diagnosis of solitary pulmonary nodules and lung masses in the 
absence of endobronchial abnormality. Chest 1996;109:620-5. 
6. 
Yarmus LB, Semaan RW, Arias SA, et al. A Randomized Controlled Trial of a Novel Sheath 
Cryoprobe for Bronchoscopic Lung Biopsy in a Porcine Model. Chest 2016;150:329-36. 
7. 
Dhooria S, Sehgal IS, Aggarwal AN, Behera D, Agarwal R. Diagnostic Yield and Safety of 
Cryoprobe Transbronchial Lung Biopsy in Diffuse Parenchymal Lung Diseases: Systematic Review and 
Meta-Analysis. Respiratory care 2016;61:700-12. 
8. 
Kendall DM, Gal AA. Interpretation of tissue artifacts in transbronchial lung biopsy specimens. 
Annals of diagnostic pathology 2003;7:20-4. 
9. 
Stewart S, Fishbein MC, Snell GI, et al. Revision of the 1996 working formulation for the 
standardization of nomenclature in the diagnosis of lung rejection. The Journal of heart and lung 
transplantation : the official publication of the International Society for Heart Transplantation 
2007;26:1229-42. 
10. 
Thiboutot J, Lee HJ, Silvestri GA, et al. Study Design and Rationale: A Multicenter, Prospective 
Trial of Electromagnetic Bronchoscopic and Electromagnetic Transthoracic Navigational Approaches for 
the Biopsy of Peripheral Pulmonary Nodules (ALL IN ONE Trial). Contemporary clinical trials 2018;71:88-
95. 
11. 
von Renteln D, Quaas A, Rosch T, et al. A novel flexible cryoprobe for EUS-guided pancreatic 
biopsies. Gastrointestinal endoscopy 2013;77:784-92. 
12. 
Yarmus L, Akulian J, Gilbert C, et al. Cryoprobe transbronchial lung biopsy in patients after lung 
transplantation: a pilot safety study. Chest 2013;143:621-6. 
13. 
Aktas Z, Gunay E, Hoca NT, et al. Endobronchial cryobiopsy or forceps biopsy for lung cancer 
diagnosis. Annals of thoracic medicine 2010;5:242-6. 
14. 
Hetzel J, Eberhardt R, Herth FJ, et al. Cryobiopsy increases the diagnostic yield of endobronchial 
biopsy: a multicentre trial. The European respiratory journal 2012;39:685-90. 
15. 
Fruchter O, Fridel L, El Raouf BA, Abdel-Rahman N, Rosengarten D, Kramer MR. Histological 
diagnosis of interstitial lung diseases by cryo-transbronchial biopsy. Respirology (Carlton, Vic) 
2014;19:683-8. 
16. 
Hagmeyer L, Theegarten D, Wohlschlager J, et al. The role of transbronchial cryobiopsy and 
surgical lung biopsy in the diagnostic algorithm of interstitial lung disease. The clinical respiratory journal 
2016;10:589-95.