A Randomized Trial of Endoscopic Biliary Co-axial Stent Placement Plus/Minus Use of Radiofrequency Ablation (RFA) for Clearance of Occluded Self Expandable Metal Stents (SEMS) in Patients With Distal Biliary Obstruction From Unresectable Biliary-pancreatic Malignancies
Phase: PHASE3
Conditions: Pancreatic Cancer, Unresectable Biliary-pancreatic Malignancies
Sponsor: Memorial Sloan Kettering Cancer Center

 
Memorial Sloan Kettering Cancer Center 
IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
 
 
A randomized trial of endoscopic biliary co-axial stent placement plus/minus use of 
radiofrequency ablation (RFA) for clearance of occluded self expandable metal stents 
(SEMS) in patients with distal biliary obstruction from unresectable biliary-pancreatic 
malignancies 
 
PROTOCOL FACE PAGE FOR 
MSKCC THERAPEUTIC/DIAGNOSTIC PROTOCOL 
 
 
Principal Investigator/Department: 
Mark Schattner, MD 
Medicine 
Co-Principal 
Investigator(s)/Department: 
Pari Shah, MD, MSCE 
Medicine 
Investigator(s)/Department: 
Robert C. Kurtz, MD 
Hans Gerdes, MD 
Robin Mendelsohn, MD 
John Wong, MD 
Mithat Gonen, PhD 
Medicine 
Medicine 
Medicine 
Medicine 
Epidemiology & Biostatistics 
Consenting Professional(s)/Department: 
Mark Schattner, MD 
Pari Shah, MD, MSCE 
Robert C. Kurtz, MD 
Hans Gerdes, MD 
Robin Mendelsohn, MD 
Medicine 
Medicine 
Medicine 
Medicine 
Medicine 
 
 
Please Note: A Consenting Professional must have completed the mandatory Human 
Subjects Education and Certification Program. 
 
 
 
 
 
Memorial Sloan-Kettering Cancer Center 
1275 York Avenue 
New York, New York 10065 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 1 of 16 

Memorial Sloan Kettering Cancer Center 
IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
Page 2 of 16 
 
 
Table of Contents 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA ..................................................................... 3 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS ................................................................................. 3 
3.0 
BACKGROUND AND RATIONALE ................................................................................... 4 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ............................................................... 6 
4.1 
Design ............................................................................................................................ 6 
4.2 
Intervention ..................................................................................................................... 6 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS ............................................................................... 6 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY ............................................................................ 7 
6.1 
Subject Inclusion Criteria ................................................................................................. 7 
6.2 
Subject Exclusion Criteria ................................................................................................ 7 
7.0 
RECRUITMENT PLAN ....................................................................................................... 7 
8.0 
PRETREATMENT EVALUATION ...................................................................................... 8 
9.0 
TREATMENT/INTERVENTION PLAN ................................................................................... 8 
10.0 EVALUATION DURING TREATMENT/INTERVENTION....................................................... 8 
11.0 TOXICITIES/SIDE EFFECTS ................................................................................................. 8 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT ......................... 9 
13.0 CRITERIA FOR REMOVAL FROM STUDY........................................................................... 9 
14.0 BIOSTATISTICS ................................................................................................................... 10 
15.0 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
10 
15.1 Research Participant Registration ................................................................................. 10 
15.2 Randomization .............................................................................................................. 11 
16.0 DATA MANAGEMENT ISSUES ....................................................................................... 11 
16.1 Quality Assurance ......................................................................................................... 11 
16.2 Data and Safety Monitoring ........................................................................................... 11 
17.0 PROTECTION OF HUMAN SUBJECTS........................................................................... 13 
17.1 Privacy .......................................................................................................................... 13 
17.2 Serious Adverse Event (SAE) Reporting ....................................................................... 13 
17.2.1................................................................................................................................... 14 
18.0 INFORMED CONSENT PROCEDURES .............................................................................. 14 
19.0 REFERENCES ...................................................................................................................... 15 
20.0 APPENDICES ....................................................................................................................... 16 

Memorial Sloan Kettering Cancer Center 
IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
Page 3 of 16 
 
 
 
 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA 
 
While advances in oncological treatments have improved survival for patients with distal 
cholangiocarcinomas and pancreatic cancers, progress in the management of malignant 
biliary obstruction and occluded SEMS has been limited. Recently, RFA, an ablative 
treatment modality for dysplastic Barrett’s esophagus and hepatocellular carcinoma, has 
been applied to malignant biliary obstruction and occluded SEMS with encouraging 
results. The efficacy and safety of this endoscopic technique however have been reported 
largely in pilot studies, case series, and retrospective reviews. The primary objective of 
this prospective randomized controlled trial is to compare, in patients with unresectable 
tumors obstructing the distal bile duct presenting with an episode of SEMS occlusion, the 
rate of failure after instent RFA followed by SEMS placement versus SEMS placement 
alone coaxially within the existing occluded SEMS. As co-axial stent placement is the 
current standard of managing an existing occluded SEMS, and to study the potential 
additive effect of RFA, the study treatment arm will consist of RFA followed by SEMS 
placement. Secondary outcomes on stent patency, as well as safety and adverse events 
will be monitored. 
 
 
 
 
 
 
 
2.1 
OBJECTIVES AND SCIENTIFIC AIMS 
 
To study the efficacy and safety of endoscopic biliary radiofrequency ablation (RFA) for 
clearance of occluded self expandable metal stents (SEMS) in unresectable malignant 
distal biliary obstruction. 
 
Primary outcome: 
 
• 
Rate of failure at or before 180 days from date of on-study procedure (co-axial 
stent placement +/- RFA) 
Indwelling SEMS 

Memorial Sloan Kettering Cancer Center 
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• 
Failure is defined as: 
Imaging findings supportive of stent occlusion (loss of stent patency, debris within 
stent, loss of or excessive pneumobilia) with one or more of the following: 
o Development of jaundice 
o Clinical cholangitis (fever, elevated white blood cell count, clinical 
impression of biliary infection) 
o Development of bilirubin rise to greater than 3.0 mg/dl in patients who had 
achieved a normal bilirubin after the on-study procedure 
o Rise in bilirubin of 2.0 mg/dl above post-procedure bilirubin nadir in patients 
who did not achieve a normal bilirubin level post procedure 
• 
There is no mandatory imaging; all imaging will be triggered by symptoms therefore 
any patient who does not have imaging by 180 days will be considered to hav        
e a patent stent and be counted as a success. 
 
Secondary outcomes: 
 
• 
Rate of technical success for endoscopic biliary RFA 
o Technical success for endoscopic biliary RFA will be defined as: 
▪ 
the ability to position the RFA catheter and deliver the prescribed 
energy. 
o Technical failure of RFA would not impact on the ability to place a co-axial 
stent. These patients would still be followed for the stent occlusion primary 
endpoint. 
• 
Rate of stent patency one month and three months post procedure 
• 
Median duration of stent patency post procedure 
• 
Radiographic evidence of local disease progression 
• 
Median survival post procedure 
• 
Incidence of procedure related complications 
• 
Incidence of adverse events within one month post procedure 
• 
Rates of 30 day and 90 day mortality 
 
3.0 
BACKGROUND AND RATIONALE 
 
Malignant biliary obstruction from intraductal disease or extrinsic compression by tumor, 
adenopathy or metastasis can occur at presentation or with progression of disease. 
Consequences of biliary obstruction include risk of cholangitis, need for hospitalization, 
procedural risks associated with decompression, interruption of chemotherapy regimen, 
and associated health care costs. Management of biliary obstruction ranges from 
percutaneous or endoscopic placement of plastic or self expandable metal biliary stents 
(SEMS) to potentially curative surgical resection, and is influenced by the stage and 
resectability of the disease, patient performance status, and the need and response to 
neoadjuvant treatment. SEMS are the treatment of choice for palliation in unresectable 
disease, and are superior to plastic stents and surgical bypass. Mean SEMS patency 
ranges between 6 months to under 1 year, but as patient survival lengthens with improved 

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oncological care, stent occlusion from benign epithelial hyperplasia, sludge, tumor 
ingrowth or overgrowth often necessitates stent clearance. 
 
Recently, radiofrequency ablation (RFA), an established endoscopic modality for treatment 
of dysplastic Barrett’s esophagus and hepatocellular carcinoma, has been applied for 
management of malignant biliary obstruction. Using a 2.6mm bipolar wire guided catheter 
(HabibTM EndoHBP catheter from EMcision, London, United Kingdom) inserted through the 
working channel of a standard side viewing endoscope, contact coagulative necrosis is 
cylindrically delivered via two ring electrodes along a length of 2.5cm across the malignant 
stricture. In 2009, this device received FDA approval to assist in the coagulation of tissue 
during endoscopic surgical procedures in the gastrointestinal tract, and has in turn been 
applied to the treatment of biliary tumors and SEMS occlusion. There are six published 
case series evaluating efficacy and safety of RFA for treating malignant biliary strictures. 
The most recent study included 58 patients from 11 Austrian centers with predominantly 
Klatskin tumor (78% of patients) undergoing 84 RFA procedures.1 The intervention 
provided was heterogeneous with 44/58 patients undergoing a single RFA, 13/58 patients 
having multiple sessions, 15/84 RFAs performed within a SEMS. 31/58 patients underwent 
other treatment modalities prior to RFA. After RFA, 35/58 patients had placement of 
SEMS, 19/58 patients had a plastic stent deployed and 4/58 patients had no stent 
placement. Median stent patency from the last RFA procedure was 170 days, with no 
difference between the SEMS and plastic stent groups. 21/58 patients required re- 
intervention after RFA. Median survival from the first RFA was 10.6 months. The most 
serious complication was partial liver infarction in a Bismuth IV Klatskin tumor who had 
RFA applied at 6 sites along the biliary tree. The patient was managed conservatively, and 
recovered. Other complications included cholangitis, cholangiosepsis, hemobilia, and 
gallbladder empyema requiring cholecystectomy. The only North American study 
prospectively included 20 patients, 11 of which had cholangiocarcinoma and 7 with 
pancreatic cancer.2 RFA significantly increased biliary stricture diameter by 3.5mm. All 
patients had placement of either a SEMS or plastic stent after RFA, with all stents patent at 
30 days post procedure. Pain was the most common complication occurring in 5/20 
patients, 1 from cholecystitis requiring percutaneous drainage, and 1 due to post ERCP 
pancreatitis managed conservatively. Earlier studies concentrating exclusively on Bismuth I 
hilar and distal cholangiocarcinomas showed intraductal RFA followed by SEMS had a 
median stent patency rate of 9 months (range 6-15 months).3 Finally, the original human 
study on biliary RFA reported in Gastrointestinal Endoscopy in 2011 described successful 
deployment of the RFA catheter in 21/22 patents (16/21 with pancreatic cancer) followed 
by successful SEMS placement in all patients, maintenance of 30 day patency and no 30 
day mortality.4 Overall, over 100 patients have undergone endoscopic biliary RFA with a 
technical success rate of over 99%, with the most common complications as cholangitis 
(5%), cholecystitis (<4%), and post ERCP pancreatitis (<3%), which is within the 
recognized range of 5% for the procedure. 
 
The efficacy of percutaneous intraductal biliary RFA through an existing blocked metal 
stent was prospectively assessed in a 9 patient study in 2014 by Pai et al.5 6/9 patients 
had cholangiocarcinoma with indwelling blocked metal stent. After external biliary drainage 

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Page 6 of 16 
 
 
with an internal-external catheter, RFA was performed percutaneously across the blocked 
stent. All patients had stent patency restored without use of secondary stents, a median 
stent patency of 102 days and no 30 day mortality. A larger retrospective study with 39 
patients, predominantly cholangiocarcinomas, who underwent percutaneous intraductal 
RFA followed by SEMS placement yielded similar median stent patency durations. All but 
one patient had patent stents at the time of last follow up or death.6 
A six month review of Memorial Sloan Kettering Cancer Center’s endoscopy database 
identified 94 endoscopic retrograde cholangiopancreatograms (ERCPs) were performed 
for malignant biliary obstruction, of which 41 patients had an existing SEMS. In 17 
patients, a SEMS was placed coaxially. 12 patients had the SEMS sweeped with an 
extraction balloon. 7 patients had a plastic biliary stent placed coaxially. In 2 patients, a 
SEMS replaced the existing stent. No changes were made to 3 SEMS. 
 
Despite changes in biliary stent design, maintaining long term biliary drainage represents a 
management challenge, especially as advances in oncological treatments improve patient 
survival. The efficacy and safety of endoscopic biliary RFA have been demonstrated 
largely in pilot studies, case series, and retrospective reviews, involving small numbers of 
patients. A prospective randomized controlled trial comparing endoscopic biliary RFA 
followed by coaxial SEMS placement versus standard of care to rigorously evaluate this 
novel technique could potentially establish a treatment for occluded SEMS. 
 
4.1 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
 
4.2 
Design 
 
In this single center study at Memorial Sloan Kettering Cancer Center, patients with any 
unresectable tumor obstructing the distal bile duct causing an indwelling biliary SEMS with 
symptoms, biochemical, radiographic and endoscopic findings supportive of an episode of 
stent occlusion are prospectively randomized to endoscopic RFA followed by SEMS 
deployment versus coaxial placement of a SEMS alone, which represents standard of 
care. The primary and secondary outcomes listed in section 2.0 will be compared between 
the two groups to determine the efficacy and safety of endoscopic biliary RFA for 
clearance of occluded SEMS in malignant biliary obstruction. 
 
4.3 
Intervention 
 
Endoscopic retrograde cholangiopancreatogram (ERCP) is performed under standard 
conditions with cannuation of the bile duct, and demonstration on a cholangiogram the 
location, diameter and length of the biliary stricture. The HabibTM EndoHBP probe 
(EMcision, London, United Kingdom) is advanced through the working channel of a side 
viewing endoscope over a 0.035in guidewire, and positioned across the occluded SEMS 
under fluoroscopy. 7-10W are usually delivered for 90 seconds with a standard high 
frequency generator, followed by a 1 minute resting period. Sequential applications of RFA 
are applied along the entire length of the stricture with an overlap of 1cm. After RFA, a 
SEMS the size determined by the endoscopist is placed. 

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Amended: 03 OCT 2016 
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5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS 
The HabibTM EndoHBP probe (EMcision, London, United Kingdom) is a commercially 
available FDA approved device for the coagulation of tissue in the gastrointestinal tract, 
and has been used for the treatment of biliary tumors and SEMS occlusion. It is a 8Fr 
(2.6mm) bipolar 0.035in wire guided catheter which is inserted through the working 
channel of a standard side viewing endoscope. Contact coagulative necrosis is cylindrically 
delivered via two radiologically marked ring electrodes along a length of 2.5cm across    
the occluded SEMS under fluoroscopic guidance. 7-10W are usually delivered for 90 
seconds with a standard high frequency generator, followed by a 1 minute resting period. 
The HabibTM EndoHBP probe (EMcision, London, United Kingdom) has been used at 
Memorial Sloan Kettering Cancer Center. 
 
6.1 
CRITERIA FOR SUBJECT ELIGIBILITY 
 
6.2 
Subject Inclusion Criteria 
 
Patients meeting all of the following criteria are eligible for study participation. 
 
• 
Patients with any tumor obstructing the distal bile duct and causing an indwelling 
biliary SEMS 
• 
Patients with jaundice or clinical cholangitis, with new elevation of alkaline 
phosphatase, total bilirubin, and imaging findings supportive of stent occlusion 
(loss of stent patency, debris within stent, loss of or excessive pneumobilia) 
• 
Age ≥ 18 years 
 
6.3 
Subject Exclusion Criteria 
 
Patients meeting the above inclusion criteria, but having any one of the following criteria 
will be excluded. Patients who: 
 
• 
Have altered gastro-duodenal or hepatobiliary anatomy such that ERCP is felt to 
be unacceptably technically difficult or unsafe 
• 
Have additional sites of biliary strictures (intrahepatic/hilar) such that ERCP 
stenting is felt to be unlikely to provide adequate clinical benefit 
• 
Have cardiac pacemakers 
• 
Have Child B/C cirrhosis 
• 
Are pregnant 
• 
Are unsuitable for endoscopy (either because of hemodynamic instability, 
respiratory distress or unsafe hematological parameters such as refractory anemia 
<7g/dL, thrombocytopenia <50K/mcL, or coagulopathy with INR >2.0) 
• 
Have biliary strictures not technically amenable to endoscopic therapy 
 
7.0 
RECRUITMENT PLAN 
 
Inpatients and outpatients of Memorial Sloan Kettering Cancer Center fitting the inclusion 
criteria in section 6.1 will be approached for the study. Eligible patients will be provided 

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Page 8 of 16 
 
 
with the IRB approved study informed consent form at the time of their consultation by the 
gastroenterology service. This consultation is completed at least one day prior to the 
procedure. A consenting professional on this study will review and have a consenting 
discussion with the participant, detailing all sections of the consent form. Participants will 
also be asked to sign a procedural consent form, detailing standard of care risks. Those 
who consent for study participation will be provided with a copy of the consent form. 
Patients will then be registered and randomized by study research staff by use of CRDB. 
Patients’ clinical details will become part of an outcomes database for future analysis. No 
reimbursements will be provided to study participants. 
 
8.0 
PRETREATMENT EVALUATION 
 
Evaluation of SEMS occlusion will be based on symptoms (abdominal pain, jaundice, 
pruritus, changes in urine/stool color, fever, chills), bloodwork (elevated white blood cell 
count, liver enzymes), imaging findings of biliary obstruction, including loss of stent 
patency, debris within stent, loss of or excessive pneumobilia, within the 2 weeks before 
study enrollment. Complete blood count, comprehensive profile and coagulation 
parameters will be obtained within 24 hours prior to the procedure. 
 
9.0 
TREATMENT/INTERVENTION PLAN 
 
Patients meeting the inclusion criteria outlined in section 6.1 will be randomized to two 
treatment arms: endoscopic biliary RFA followed by SEMS deployment (study arm) versus 
coaxial placement of SEMS alone (standard of care). Existing studies outlining safety and 
efficacy of RFA for management of malignant biliary obstruction and occluded SEMS are 
outlined in section 3.0. The procedural details of endoscopic biliary RFA are described in 
section 4.2. Primary and secondary outcomes defined in section 2.0 will be monitored. 
 
10.0 EVALUATION DURING TREATMENT/INTERVENTION 
 
At the time of endoscopy, the occluded SEMS position, length and diameter will be 
documented prior to intervention, as will the number, duration and total energy delivered 
during RFA for the study arm. Characteristics of the SEMS deployed will be recorded. 
Post procedure complications will be evaluated and managed according to standard 
clinical practice. Patients without adverse events will be discharged within 48hours after 
procedure, and followed to monitor primary and secondary outcomes. All additional 
imaging and laboratory studies will be conducted as clinically indicated and recorded. 
 
11.0 TOXICITIES/SIDE EFFECTS 
 
Among published studies, over 100 patients have undergone endoscopic biliary RFA with 
a technical success rate of over 99%, with the most common complications as cholangitis 
(5%) all treated conservatively, cholecystitis (<4%) requiring either percutaneous drainage 
or cholecystectomy, hemobilia (<3%), and post ERCP pancreatitis (<3%) all treated 
conservatively, and which is within the recognized 5% incidence post ERCP in general. 
Other complications occurring at less than 1% include: liver infarction managed 

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Amended: 03 OCT 2016 
Page 9 of 16 
 
 
conservatively, and left bundle branch block managed conservatively. All cases of 
cholangitis, hemobilia, liver infarction, left bundle branch block were reported from a single 
study where 78% of the study group consisted of Klatskin tumor, a disease site which is 
excluded from this study. All procedural related adverse events on study will be captured 
by the Research Study Assistant (RSA) and reported to the IRB if serious. 
 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT 
 
Rate of failure for biliary stent obstruction after randomization to either instent RFA or 
coaxial SEMS placement alone serves as the primary objective to assess treatment 
efficacy. SEMS re-occlusion will be based on symptoms (jaundice or cholangitis), 
bloodwork (elevation of total bilirubin), imaging findings of biliary obstruction, including loss 
of stent patency, debris within stent, loss of or excessive pneumobilia. Study participants 
will be instructed to contact study physicians with any of the above symptoms of biliary 
stent occlusion for further evaluation. Please see section 2.0 for secondary outcomes. 
 
 
13.0 
CRITERIA FOR REMOVAL FROM STUDY 
 
Enrolled patients who withdraw consent for continued study participation, and patients 
who do not achieve clearance of occluded SEMS by the intended randomized treatment 
will be removed from the study, and will be managed based on standard of care. 
 
Any patient who withdraws consent prior to randomization will be replaced in the study. 
Any patient who withdraws consent after randomization will not be replaced. 

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IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
Page 10 of 16 
 
 
 
 
14.1 
BIOSTATISTICS 
 
This is a prospective randomized study comparing RFA followed by SEMS deployment 
versus placement of a SEMS alone. Patients with unresectable cancers of the distal bile 
duct or head of the pancreas with symptoms, biochemical, radiographic and endoscopic 
findings supportive of biliary obstruction will be randomized to one of these two arms and 
the primary endpoint, rate failure 180 days, will be compared across the two arms. Based 
on a review of internal data, rate of failure at 180 days is anticipated to be 60% with SEMS 
alone. Randomizing a total of 170 patients will give us approximately 80% power to detect 
an odds ratio of 2.5(i.e. a rate of 37% in the RFA+SEMS group) while controlling the Type I 
error at 5%. This sample size also allows for one interim analysis halfway through the trial 
(after 85 patients are randomized) using the O’Brien-Fleming boundary. If the p-value at 
the interim analysis is less than 0.003, the study will stop early for efficacy and if p>0.712  
it will stop for futility. If the study does not stop early, final analysis will use a p-            
value threshold of 0.048 for significance. 
 
Primary analysis will follow the intent-to-treat principle, with each patient analyzed in its 
randomized group even if the patient received another treatment or was not treated at all. 
Patients who do not receive any treatment or who die before 6 months will be counted as 
events regardless of whether their stents failed. 
 
Rate of technical success for the endoscopic RFA group will be reported. All other 
secondary endpoints will be presented with summary statistics or contingency tables as 
appropriate and compared across the two groups with the tests listed next to them.: 
 
• 
Rate of stent patency one month and three months post procedure: chi-square test 
• 
Median duration of stent patency post procedure: log-rank test 
• 
Median survival post procedure: log-rank test 
• 
Incidence of procedure related complications: chi-square test 
• 
Incidence of adverse events within one month post procedure: chi-square test 
• 
Rates of 30-day and 90-day mortality: chi-square test. 
 
 
15.1 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
 
15.2 
Research Participant Registration 
 
Confirm eligibility as defined in the section entitled Criteria for Patient/Subject Eligibility. 
 
Obtain informed consent, by following procedures defined in section entitled Informed 
Consent Procedures. 
 
During the registration process registering individuals will be required to complete a 
protocol specific Eligibility Checklist. 

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Page 11 of 16 
 
 
All participants must be registered through the Protocol Participant Registration (PPR) 
Office at Memorial Sloan Kettering Cancer Center. PPR is available Monday through 
Friday from 8:30am – 5:30pm at 646-735-8000. Registrations must be submitted via the 
PPR Electronic Registration System (http://ppr/). The completed signature page of the 
written consent/RA or verbal script/RA, a completed Eligibility Checklist and other relevant 
documents must be uploaded via the PPR Electronic Registration System. 
15.3 
Randomization 
 
After consent and prior to the procedure, patients will be randomized into either the 
intervention or control group on a 1:1 ratio. Patients will be assigned to either group by the 
institutional Clinical Research Database (CRDB). 
 
16.1 
DATA MANAGEMENT ISSUES 
 
A Research Study Assistant (RSA) will be assigned to the study. The responsibilities of 
the RSA include project compliance, data collection, abstraction and entry, data reporting, 
regulatory monitoring, problem resolution and prioritization, and coordinating the activities 
of the protocol study team. 
 
The RSA will track and collect all the information gathered by the study clinicians and 
enter the data into the institutional Clinical Research Database (CRDB). 
16.2 
Quality Assurance 
 
Throughout the life of the study, the study team comprising of the PI, research fellows, 
RSA, and CRC will meet regularly. During these meetings, they will address accrual rates, 
review adverse events, and discuss any challenges with using the device in this 
population. Weekly registration reports will be generated to monitor patient accruals and 
completeness of data. Routine data quality reports will be generated to assess missing 
data and inconsistencies. Accrual rates and accuracy of evaluations and follow-up will be 
monitored periodically throughout the study period and potential problems will be brought 
to the attention of the PI and CRM for discussion and action. 
 
Random sample data quality audits will be performed on a recurring basis and evaluated 
at the study team meetings. 
 
16.3 
Data and Safety Monitoring 
 
The Data and Safety Monitoring (DSM) Plans at Memorial Sloan Kettering Cancer Center 
were approved by the National Cancer Institute in September 2001. The plans address 
the new policies set forth by the NCI in the document entitled “Policy of the National 
Cancer Institute for Data and Safety Monitoring of Clinical Trials” which can be found at:  
http://cancertrials.nci.nih.gov/researchers/dsm/index.html. The DSM Plans at MSKCC 
were established and are monitored by the Office of Clinical Research. The MSKCC Data 
and Safety Monitoring Plans can be found on the MSKCC Intranet at:  
http://mskweb2.mskcc.org/irb/index.htm 

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Amended: 03 OCT 2016 
Page 12 of 16 
 
 
There are several different mechanisms by which clinical trials are monitored for data, 
safety and quality.  There are institutional processes in place for quality assurance (e.g., 
protocol monitoring, compliance and data verification audits, therapeutic response, and 
staff education on clinical research QA) and departmental procedures for quality control, 
plus there are two institutional committees that are responsible for monitoring the activities 
of our clinical trials programs. The committees: Data and Safety Monitoring Committee 
(DSMC) for Phase I and II clinical trials, and the Data and Safety Monitoring Board 
(DSMB) for Phase III clinical trials, report to the Center’s Research Council and 
Institutional Review Board. 
 
During the protocol development and review process, each protocol will be assessed for 
its level of risk and degree of monitoring required. Every type of protocol (e.g., NIH 
sponsored, in-house sponsored, industrial sponsored, NCI cooperative group, etc.) will be 
addressed and the monitoring procedures will be established at the time of protocol 
activation. 

Page 13 of 16 
Memorial Sloan Kettering Cancer Center 
IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
 
 
 
 
 
17.1 
PROTECTION OF HUMAN SUBJECTS 
 
Participants will be informed that information collected during their participation in this study 
is considered confidential. All data gathered will be kept in a secured location and available 
only to members of the research study team. Findings will be presented in aggregate form 
only - with no references made to the individual participant’s data. Confidentiality of each 
participant’s data will be protected with utmost care; data will be identified solely by a code 
number. A list matching participant’s names and code numbers will be maintained on a 
secure and password protected database in MSKCC servers. Participation in this study is 
entirely voluntary. All participants will be required to sign a statement of informed consent 
that adheres to MSKCC guidelines. Should a patient decide not to participate in this study or 
to withdraw their consent to participate at any time during the study, their treatment at 
MSKCC or participating institutions will in no way be compromised. 
17.2 
Privacy 
 
MSKCC’s Privacy Office may allow the use and disclosure of protected health information 
pursuant to a completed and signed Research Authorization form. The use and disclosure of 
protected health information will be limited to the individuals described in the Research 
Authorization form. A Research Authorization form must be completed by the Principal 
Investigator and approved by the IRB and Privacy Board (IRB/PB). 
17.3 
Serious Adverse Event (SAE) Reporting 
 
An adverse event is considered serious if it results in ANY of the following outcomes: 
• 
Death 
• 
A life-threatening adverse event 
• 
An adverse event that results in inpatient hospitalization or prolongation of existing 
hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect 
• 
Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition 
Note: Hospital admission for a planned procedure/disease treatment is not considered an 
SAE. 
 
SAE reporting is required as soon as the participant signs consent.  SAE reporting is 
required for 30-days after the participant’s last investigational treatment or intervention. Any 
events that occur after the 30-day period and that are at least possibly related to protocol 
treatment must be reported. 

Page 14 of 16 
Memorial Sloan Kettering Cancer Center 
IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
 
 
If an SAE requires submission to the IRB office per IRB SOP RR-408 ‘Reporting of Serious 
Adverse Events’, the SAE report must be sent to the IRB within 5 calendar days of the event. 
The IRB requires a Clinical Research Database (CRDB) SAE report be submitted 
electronically to the SAE Office as follows: 
 
Reports that include a Grade 5 SAE should be sent to saegrade5@mskcc.org.  All other 
reports should be sent to sae@mskcc.org. 
 
The report should contain the following information: 
Fields populated from CRDB: 
• 
Subject’s initials 
• 
Medical record number 
• 
Disease/histology (if applicable) 
• 
Protocol number and title 
Data needing to be entered: 
• 
The date the adverse event occurred 
• 
The adverse event 
• 
The grade of the event 
• 
Relationship of the adverse event to the treatment (drug, device, or intervention) 
• 
If the AE was expected 
• 
The severity of the AE 
• 
The intervention 
• 
Detailed text that includes the following 
o A explanation of how the AE was handled 
o A description of the subject’s condition 
o Indication if the subject remains on the study 
• 
If an amendment will need to be made to the protocol and/or consent form 
• 
If the SAE is an Unanticipated Problem 
 
The PI’s signature and the date it was signed are required on the completed report. 
 
 
 
17.2.1 
 
Not applicable. 
 
 
 
18.1 
INFORMED CONSENT PROCEDURES 
 
Before protocol-specified procedures are carried out, consenting professionals will explain 
full details of the protocol and study procedures as well as the risks involved to participants 
prior to their inclusion in the study. Participants will also be informed that they are free to 

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IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
 
 
withdraw from the study at any time. All participants must sign an IRB/PB-approved consent 
form indicating their consent to participate. This consent form meets the requirements of the 
Code of Federal Regulations and the Institutional Review Board/Privacy Board of this Center. 
The consent form will include the following: 
 
1. The nature and objectives, potential risks and benefits of the intended study. 
2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard and 
investigational therapies. In addition, patients will be offered an option of supportive 
care for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions and to 
withdraw from participation at any time. 
 
Before any protocol-specific procedures can be carried out, the consenting professional will 
fully explain the aspects of patient privacy concerning research specific information. In 
addition to signing the IRB Informed Consent, all patients must agree to the Research 
Authorization component of the informed consent form. 
 
Each participant and consenting professional will sign the consent form. The participant must 
receive a copy of the signed informed consent form. 
 
 
19.0 
REFERENCES 
 
1Dolak W, Schreiber F, Schwaighofer H et al. Endoscopic radiofrequency ablation for 
malignant biliary obstruction: a nationwide retrospective study of 84 consecutive applications. 
Surg Endosc. 2014 Mar;28(3):854-60 
2Figueroa-Barojas P, Bakhru MR, Habib NA et al. Safety and efficacy of radiofrequency 
ablation in the management of unresectable bile duct and pancreatic cancer: a novel 
palliation technique. J Oncol. 2013 doi: 10.1155/2013/910897 
3 Alis H, Sengoz C, Gonenc M et al. Endobiliary radiofrequency ablation for malignant biliary 
obstruction. Hepatobiliary Pancreat Dis Int. 2013 12(4):423-7 
4 Steel A, Postgate AJ, Khorsandi S et al. Endoscopically applied radiofrequency ablation 
appears to be safe in the treatment of malignant biliary obstruction. Gastrointest Endosc. 
2011 73(1):149-53 
5 Pai M, Valek V, Tomas A et al. Percutaneous intraductal radiofrequency ablation for 
clearance of occluded metal stent in malignant biliary obstruction: Feasibility and early 
results. Cardiovasc Intervent Radiol. 2014 Feb;37(1):235-40 
6 Mizandari M, Pai M, Xi F et al. Percutaneous intraductal radiofrequency ablation is a safe 
treatment for malignant biliary obstruction: Feasibility and early results. Cardiovasc Intervent 
Radiol. 2013 Jun;36(3):814-9. 

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IRB #: 14-260 A(3) 
Amended: 03 OCT 2016 
 
 
20.0 
APPENDICES 
 
None.