Effectiveness and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer Screening: A Clinical Study in Brazil and the United States
Phase: PHASE2
Conditions: Suspected or Known Squamous Cell Neoplasia, Prior History of Squamous Cell Dysplasia and /or Neoplasia
Sponsor: Baylor College of Medicine

NIH-FDA Phase 2 and 3 IND/IDE Clinical Trial Protocol 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
i 
EFFECTIVENESS, EFFICIENCY, AND PERFORMANCE OF A 
MOBILE, AUTOMATED, OPTICAL BIOPSY TECHNOLOGY 
FOR ESOPHAGEAL CANCER SCREENING: A CLINICAL 
STUDY IN BRAZIL AND THE UNITED STATES 
Short Title: AI-mHRME in Brazil and the United States for Esophageal Cancer Screening 
Protocol Number: H-53483 
National Clinical Trial (NCT) Identified Number: NCT06435286 
Principal Investigator: Mimi Tan, MD, MPH 
IND Sponsor: Mimi Tan, MD, MPH 
Funded by: National Cancer Institute 
Version Number: v.2.0 
6 November 2025 
 
Summary of Changes from Previous Version: 
Affected 
Section(s) 
Summary of Revisions Made 
Rationale 
Title page 
Changed the Principal Investigator, IND 
Sponsor to Mimi Tan 
New Sponsor-Investigator for IND 
5 Study 
Population, 
5.5 Strategies 
for 
Recruitment 
and 
Retention 
Changed the information that the research 
population will be identified by Dr. Mimi Tan 
at both Baylor St. Luke’s Medical Center 
(BSLMC) and at Ben Taub Hospital (BTH) 
Mimi Tan is the new Baylor College of 
Medicine Principal Investigator 
10.1.5 Key 
Roles and 
Study 
Governance 
Changed the Baylor College of Medicine 
Principal Investigator and corresponding 
contact information to Dr. Mimi Tan 
Mimi Tan is the new Baylor College of 
Medicine Principal Investigator 

NIH-FDA Phase 2 and 3 IND/IDE Clinical Trial Protocol 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
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10.1.7 Clinical 
Monitoring 
Changed the Baylor College of Medicine 
Principal Investigator for clinical monitoring to 
Dr. Mimi Tan 
Mimi Tan is the new Baylor College of 
Medicine Principal Investigator 
10.1.11 
Publication 
and Data 
Sharing Policy 
Changed the Baylor College of Medicine 
Principal Investigator to Dr. Mimi Tan 
Mimi Tan is the new Baylor College of 
Medicine Principal Investigator 

  
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
ii 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 3 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 4 
2 
INTRODUCTION ............................................................................................................................................ 4 
2.1 
Study Rationale .................................................................................................................................... 4 
2.2 
Background........................................................................................................................................... 5 
2.3 
Risk/Benefit Assessment .................................................................................................................... 6 
2.3.1 
Known Potential Risks ..................................................................................................... 6 
2.3.2 
Known Potential Benefits ................................................................................................ 8 
2.3.3 
Assessment of Potential Risks and Benefits ................................................................ 8 
3 
OBJECTIVES AND ENDPOINTS ................................................................................................................ 9 
4 
STUDY DESIGN ............................................................................................................................................. 9 
4.1 
Overall Design ...................................................................................................................................... 9 
4.2 
Scientific Rationale for Study Design.............................................................................................. 10 
4.3 
Justification for Dose ......................................................................................................................... 11 
4.4 
End of Study Definition ..................................................................................................................... 11 
5 
STUDY POPULATION ................................................................................................................................ 11 
5.1 
Inclusion Criteria ................................................................................................................................ 11 
5.2 
Exclusion Criteria ............................................................................................................................... 12 
5.3 
Lifestyle Considerations .................................................................................................................... 12 
5.4 
Screen Failures .................................................................................................................................. 12 
5.5 
Strategies for Recruitment and Retention ...................................................................................... 12 
6 
STUDY INTERVENTION ............................................................................................................................ 13 
6.1 
Study Intervention(s) Administration ............................................................................................... 13 
6.1.1 
Study Intervention Description ..................................................................................... 13 
6.1.2 
Dosing and Administration ............................................................................................ 15 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 15 
6.2.1 
Acquisition and accountability ...................................................................................... 15 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 16 
6.2.3 
Product Storage and Stability ....................................................................................... 16 
6.2.4 
Preparation ...................................................................................................................... 17 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 17 
6.4 
Study Intervention Compliance ........................................................................................................ 17 
6.5 
Concomitant Therapy ........................................................................................................................ 18 
6.5.1 
Rescue Medicine ............................................................................................................ 18 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT DISCONTINUATION OR 
WITHDRAWAL .......................................................................................................................................................... 18 
7.1 
Discontinuation of Study Intervention ............................................................................................. 18 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 18 
7.3 
Lost to Follow-Up ............................................................................................................................... 18 
8 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................................... 19 
8.1 
Efficacy Assessments ....................................................................................................................... 19 
8.2 
Safety and Other Assessments ....................................................................................................... 20 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 20 

  
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8.3.1 
Definition of Adverse Events (AE) ............................................................................... 20 
8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 20 
8.3.3 
Classification of an Adverse Event .............................................................................. 21 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 21 
8.3.5 
Adverse Event Reporting .............................................................................................. 22 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 24 
8.3.7 
Reporting Events to Participants ................................................................................. 24 
8.3.8 
Events of Special Interest ............................................................................................. 24 
8.3.9 
Reporting of Pregnancy ................................................................................................ 24 
8.4 
Unanticipated Problems .................................................................................................................... 24 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 24 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 24 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................... 25 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 25 
9.1 
Statistical Hypotheses ....................................................................................................................... 25 
9.2 
Sample Size Determination .............................................................................................................. 25 
9.2.1 
Analysis of the Primary Endpoint ................................................................................. 26 
9.2.2 
Analysis of the Secondary Endpoint(s) ....................................................................... 26 
9.2.3 
Safety Analyses .............................................................................................................. 26 
9.2.4 
Planned Interim Analyses ............................................................................................. 26 
9.2.5 
Sub-Group Analyses ..................................................................................................... 27 
9.3 
Populations for Analyses .................................................................................................................. 27 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 27 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 27 
10.1.1 
Informed Consent Process ........................................................................................... 27 
10.1.2 
Study Discontinuation and Closure ............................................................................. 28 
10.1.3 
Confidentiality and Privacy ........................................................................................... 28 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 29 
10.1.5 
Key Roles and Study Governance .............................................................................. 29 
10.1.6 
Safety Oversight ............................................................................................................. 30 
10.1.7 
Clinical Monitoring .......................................................................................................... 30 
10.1.8 
Quality Assurance (QA) and Quality Control (QC) .................................................... 30 
10.1.9 
Data Handling and Record Keeping ............................................................................ 31 
10.1.10 
Protocol Deviations ........................................................................................................ 31 
10.1.11 
Publication and Data Sharing Policy ........................................................................... 32 
10.1.12 
Conflict of Interest Policy .............................................................................................. 32 
10.2 
Additional Considerations ................................................................................................................. 32 
10.3 
Abbreviations ...................................................................................................................................... 33 
10.4 
Protocol Amendment History ........................................................................................................... 35 
11 
REFERENCES ............................................................................................................................................. 36 
 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
1 
STATEMENT OF COMPLIANCE 
The trial will be conducted in accordance with the International Conference on Harmonisation Good 
Clinical Practice (ICH GCP), applicable United States (US) Code of Federal Regulations (CFR), and the 
National Cancer Institute’s (NCI) Terms and Conditions of Award. The Principal Investigator will assure 
that no deviation from, or changes to the protocol will take place without prior agreement from the New 
Drug (IND) or Investigational Device Exemption (IDE) sponsor, funding agency 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 and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be 
submitted to the IRB for review and approval. The protocol and the consent form must be approved 
before any participant is enrolled. Any amendment to the protocol will require review and approval by 
the IRB before the changes are implemented in the study. All changes to the consent form will be IRB 
approved; a determination will be made regarding whether new consent needs to be obtained from 
participants who provided consent using a previously approved consent form. 
1 
 
PROTOCOL SUMMARY 
1.1 
SYNOPSIS 
Title: 
Effectiveness, Efficiency, and Performance of a Mobile, Automated, 
Optical Biopsy Technology for Esophageal Cancer Screening: A Clinical 
Study in Brazil and the United States 
 
Study Description: 
We will develop and evaluate the diagnostic performance, efficiency, and 
impact of the computer-assisted AI-based HRME in diverse clinical 
environments in the US and Brazil to facilitate implementation. The main 
hypothesis of the research study is that AI-mHRME will increase LCE 
accuracy. Additional exploratory hypotheses include that AI-mHRME will 
(1) increase AI-mHRME accuracy in novice endoscopists and be non-
inferior to expert endoscopists, (2) increase user confidence among expert 
and novice endoscopists, and (3) increase LCE efficiency and impact by 
reducing biopsies and second procedures. 
Objectives: 
 
 
Primary Objective: To evaluate the specificity among novices using AI-
mHRME during esophageal cancer screening and surveillance. Our goal is 
to increase the specificity among novices using AI-mHRME without 
significant reduction in sensitivity. 
 
Secondary Objectives: (A) To assess the diagnostic performance of AI-
mHRME; 
 
(B) To evaluate provider confidence (experts and novices) in clinically 
interpreting mHRME (pre- and post-use of AI-mHRME); 
 
(C) To assess the clinical impact following AI-mHRME;  
 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
2 
(D) To determine the diagnostic yield of AI-mHRME  
 
(E) To determine procedure efficiency of AI-mHRME, including subjects 
saved any biopsy and biopsy efficiency. 
Endpoints: 
Primary Endpoint: Specificity (SP) of AI-mHRME in novices  
 
Secondary Endpoints: (A) Sensitivity, specificity, positive predictive value, 
negative predictive value (SN, SP,PPV, NPV) of AI-mHRME;  
 
(B) Provider (experts and novices) reported confidence level (low or high) 
in pre- and post- use of AI-mHRME; 
 
(C) Change in clinical plan (biopsy vs. no biopsy vs. treat) post-AI mHRME; 
 
(D) Truly neoplastic biopsies/total biopsies obtained; 
 
(E) Subjects saved any biopsy: number of patients correctly saved any 
biopsy; Biopsy efficiency: the total number of biopsies saved. 
Study Population: 
Specify the sample size, gender, age, demographic group, general health 
status, and geographic location. 
We will enroll 200 subjects. Subjects will be patients for ESCN screening or 
surveillance who meet inclusion criteria and consent to study 
participation. Subjects must be 18 years or older, of any gender,  race and 
ethnicity, categorized as ESCN screening or ESCN surveillance, and present 
to the endoscopy units in Houston, Texas, and Barretos and Sao Paulo, 
Brazil. 
Phase: 
2 
Description of 
Sites/Facilities Enrolling 
Participants: 
Baylor St. Luke’s Medical Center (private outpatient clinic), Houston, Texas 
Ben Taub Hospital, Harris Health System (public hospital), Houston, Texas 
Instituto do Câncer do Estado de São Paulo (public tertiary care hospital), 
São Paulo, Brazil 
Hospital de Amor (non-profit tertiary care hospital), Barretos, Brazil 
Description of Study 
Intervention: 
High-resolution microendoscope (HRME): A fiber-optic fluorescence 
microscope intended for in vivo imaging of epithelial cell nuclei. The 
primary optical components are a blue light-emitting diode, excitation 
filter, dichroic mirror, objective lens, fiber-optic probe, tube lens, emission 
filter, and high-frame-rate camera sensor. The HRME system includes a 
laptop computer and user interface/software. 
Proflavine hemisulfate: 10 ml or 10 cc of sterile 0.01% w/v proflavine 
hemisulfate solution administered topically using spray cathether onto the 
esophageal lining through the endoscope biopsy channel during 
endoscopy. 
Study Duration: 
3 years / 36 months 
Participant Duration: 
7 days  
 
 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
3 
1.2 
SCHEMA 
Esophageal AI-mHRME Study Flow diagram 
 
Prior to  
Enrollment 
 
 
 
 
 
 
 
 
 
 
Day 0 
Procedure 
In-person  
 
 
 
Visit 2 
Day 7 
Phone call 
 
 
Visit 3 
Day 180 
EMR Review 
 
 
 
 
Obtain informed consent. Screen potential participants by inclusion and exclusion criteria; 
obtain data on demographic, medical and family history, smoking and alcohol, baseline 
symptoms, previous cancer treatments and pathology. (Forms 1-8) 
Perform standard of care endoscopy procedure. 
Complete white light endoscopy, narrow band imaging, Lugol’s chromoendoscopy of the 
esophagus, spray with Lugol’s iodine.  
Administer study device: AI-mHRME imaging with proflavine hemisulfate. 
Complete esophageal assessment and collect biopsies of all Lugol’s abnormal areas and 
1-2 normal areas. (Forms 9-10) 
Electronic medical record review to record if subject had a standard of care endoscopy 
procedure after the study procedure, and if there was any treatment during Day 0 and 
Day 180. 
Complete study completion form (Form 14) 
Review and note pathology results from biopsies collected on Day 0. (Form 11) 
Phone call to assess follow-up symptoms and any adverse events after endoscopy 
procedure. (Form 12-13)  
Screening 
Register 
Surveillance 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
4 
1.3 
SCHEDULE OF ACTIVITIES (SOA) 
Procedures 
Study 
Procedure, 
Day 0 
Phone Call 
Day 7 ± 1 day 
Medical Record 
Review 
Day 180 ± 7 days 
Form No. 1: Study Screening  
X 
 
 
Form No. 2: Study Eligibility Criteria 
X 
 
 
Registration 
X 
 
 
Form No. 3: General Subject 
Information 
X 
 
 
Form No. 4: Medical history 
X 
 
 
Form No. 5: Smoking History 
X 
 
 
Form No. 6: Alcohol History 
X 
 
 
Form No. 7: Pathology Review 
X 
 
 
Form No. 8: Baseline Symptoms 
X 
 
 
Administer study intervention (AI-
mHRME and proflavine) 
X 
 
 
Form No. 9: Endoscopic Assessment 
X 
 
 
Form No. 10: NBI, Lugol’s, and HRME 
Interpretations and Biopsy Collection 
X 
 
 
Collect pathology results 
 
X 
 
Form No. 11: Local and Central 
Pathology Read 
 
X 
 
Call participant for follow-up 
 
X 
 
Form No. 12: 7-Day Follow-Up 
Symptoms 
 
X 
 
Form No. 13: Additional Adverse Event 
Questions 
 
X 
 
Form No. 14: Study Completion 
 
X 
 
Form No. 15: 180 Day Follow-Up 
 
 
X 
2 
 
INTRODUCTION 
2.1 
STUDY RATIONALE 
Esophageal cancer is the 6th most common cause of cancer-related mortality worldwide. While 
esophageal squamous cell neoplasia (ESCN) carries a significant global burden, those in certain 
underserved geographic regions (South America, eastern Africa, eastern Iran, and northern China) have 
exceptionally high incidence and mortality rates due to a lack of endoscopic screening capacity. While 
endoscopy with Lugol’s chromoendoscopy or “digital” chromoendoscopy has shown high sensitivity 
(>95%) for screening, specificity is poor (<60%), and false-positive results abound due to confounding 
inflammatory areas. As a result, the standard-of-care endoscopy produces many unnecessary biopsies, 
increasing the risk and cost of endoscopic screening and surveillance. 
 
In our ongoing R01 project, we developed and validated a mobile, high-resolution microendoscope 
(mHRME) for screening and surveillance of ESCN. Despite over two years of COVID-19 delays, which 
significantly impacted the Chinese sites, we completed (1) a randomized, controlled clinical trial (USA and 
China; n=916) of mHRME with visual interpretation in patients undergoing screening or surveillance for 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
5 
ESCN, (2) deep-learning software algorithms for automated detection of neoplastic images, and (3) a pilot 
trial (n=41) of the software-assisted mHRME in Brazil in January 2022. The trial revealed higher specificity 
for qualitative (visual) interpretation by experts but not novices in the surveillance arm (100% vs. 19%, 
p<0.05). In the screening arm, diagnostic yield (neoplastic biopsies/total biopsies) increased 3.6 times (8 
to 29%); 16% of patients were correctly spared any biopsy, and 18% had a change in clinical plan. In a 
single-arm pilot study, we evaluated an artificial intelligence-based mobile HRME (AI-mHRME) in 41 
Brazilian participants. This pilot study in January 2022 confirmed that quantitative interpretation (AI-
mHRME) doubled diagnostic yield, improved endoscopists’ confidence, and had a significant clinical 
impact (change of clinical plan in 64%).  
 
This study will build on this valuable global data to optimize an AI-mHRME and evaluate its clinical impact 
and implementation potential in the USA and Brazil's ethnically and socioeconomically diverse 
populations. 
2.2 
BACKGROUND 
ESCN Worldwide: Esophageal cancer is the 6th most common cause of cancer-related mortality 
worldwide.1 Despite advances in chemoradiation therapy, 5-year survival remains <15% due to diagnosis 
at an advanced, incurable stage.1 Indeed, survival drops markedly once the tumor has breached the 
mucosal layer, reinforcing the importance of early detection.2  While the disease carries a significant global 
burden (including the USA), specific geographic areas (South America, Iran, China) have exceptionally high 
incidence rates. The reasons for this are multifactorial (smoking, alcohol, low socioeconomic status, 
thermal injury/hot beverages, nutritional deficiency).3 In Brazil, age-standardized incidence rates are as 
high as 9.2 per 100,000 people.4 Endoscopic screening and surveillance protocols have been implemented 
with limited success, and the incidence-to-mortality ratio remains a dismal 1:1.1 In 2019 alone, the WHO 
reported over 8,000 deaths due to esophageal cancer in Brazil.4,5 
 
Current Screening for ESCN and Its Limitations: At present, the ‘gold standard’ endoscopic evaluation for 
squamous neoplasia involves Lugol’s iodine staining (Lugol’s chromoendoscopy, LCE) of the esophagus 
with targeted biopsy of unstained (abnormal) areas. Screening is performed in high-risk patients, e.g., 
those with a history of head and neck cancer, positive balloon cytology, or living in high-prevalence global 
areas.6,7 While LCE is the most sensitive (>97%) method for ESCN detection, specificity is poor (<60%);8,9 
areas of inflammation appear unstained and indistinguishable from cancer, leading to high false-positive 
rates. As a result, patients undergo multiple unnecessary biopsies with subsequent increases in cost and 
risk. Narrow-band imaging (NBI) has been proposed as a ‘red flag’ alternative to LCE that does not require 
a dye. While the sensitivity of this method (90.5%)10 has approached that of LCE (>97%), more extensive 
trials are needed, and the technology is not available in many centers. LCE remains the gold standard for 
esophageal screening but is limited by its high false-positive rates. 
 
Confocal microendoscopy, a high-resolution imaging technique that evaluates the mucosa at a 1 µm 
resolution and 1100X magnification, has revolutionized the endoscopic surveillance of cancer by allowing 
endoscopists to see neoplasia at a subcellular level.11 When confocal microscopy is coupled with wide- 
field LCE, accuracy rates reach 95% with marked improvement in specificity.12 Nonetheless, the 
technology is expensive ($150,000-$250,000) and requires considerable infrastructure and intravenous 
contrast injection. Lastly, the interpretation of images calls for a high level of user training and expertise. 
As such, confocal platforms are confined to tertiary centers in high-resource settings. 
 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
6 
Artificial Intelligence (AI) and Esophageal Cancer Screening – Acceptability and Barriers: Recently, 
researchers have used AI-based algorithms to overcome the many pitfalls of ESCN diagnosis.13,14 Indeed, 
many AI systems have diagnostic capabilities comparable or superior to expert endoscopists; however , 
AI algorithms that use microscopic imaging typically have higher specificity than AI algorithms that use 
“red flag” imaging (e.g., NBI).11 Using AI as a diagnostic aid increases the accuracy of endoscopists, 
especially those with less experience15,16 Thus, AI can potentially enhance the diagnosis of ESCN and 
improve non-experts' diagnostic performance. Nonetheless, there are several potential barriers to the 
implementation of AI, including patient mistrust,15,16 lack of local expertise,17 lack of AI knowledge among 
medical professionals,18 regulatory barriers,19 and AI bias (e.g., skewed or less accurate algorithms due to 
lack of diverse and representative population data).20,21 
 
Need for Low-Cost, High-Resolution Imaging: Given the limitations of existing approaches, the limited 
availability and high cost of current confocal platforms, and the uniformly poor prognosis of esophageal 
cancer when it has breached the epithelium, there is a great need for accurate and accessible technologies 
that improve early detection. A reliable, robust, low-cost method of identifying ESCN at an early, 
removable stage would improve existing endoscopic strategies and enable more accurate and selective 
biopsies. Additionally, the ability to delineate normal from neoplastic mucosa in real time (with computer 
algorithms) can reduce the number of patients lost to follow-up, improve user expertise and confidence, 
and facilitate immediate, minimally invasive endoscopic therapy, such as endoscopic mucosal resection, a 
less costly alternative to surgery with far less morbidity.22 
 
Most AI research is severely limited by (1) lack of heterogeneity in patient data and (2) outcomes that are 
not clinically relevant (e.g., ROC curves rather than clinical impact analysis). There is an excellent need for 
evaluations of AI-based approaches that study human-machine interaction, clinical impact, and results in 
diverse patient populations. Our proposed trial (diverse settings, patient, and user/stakeholder 
evaluations) will break new ground and help address these gaps. Our study endpoints (i.e., provider 
confidence, clinical impact, procedure efficiency, etc.) directly address the issues of clinical relevance and 
potential for dissemination. 
2.3 
RISK/BENEFIT ASSESSMENT 
2.3.1 KNOWN POTENTIAL RISKS 
Many side effects go away soon after the endoscopy procedure, but in some cases, side effects may be 
serious, long-lasting, or permanent and may even cause death. The participant must tell the study staff 
about any side effects that they may have had, even if they do not think they are related to the procedure. 
2.3.1.1 IMMEDIATE RISKS 
Immediate risks from the study procedure with proflavine and HRME: 
 
• 
Allergic reaction (anaphylaxis). There is the possibility of a severe allergic reaction to Proflavine 
Hemisulfate, the contrast dye, in which the participant may have difficulty breathing and may have 
blood pressure drop. If this were to occur, there are procedures in place to treat the subject 
immediately during endoscopy. 
• 
Specimen Imaging Probe (AI-mHRME): There are no known risks from using the imaging probe (AI-
mHRME). 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
7 
• 
Anesthesia. There may be additional risks from the added time of additional sedation, such as 
decreased blood pressure. If this were to occur, there are procedures in place to treat the subject 
immediately during endoscopy. 
• 
Aspiration. Inhaling fluid into the lungs during endoscopy might cause lung inflammation. Safeguards 
to prevent this from happening while the participant is under anesthesia will be in place during and 
after the procedure, and the participant's breathing and other vital signs will be carefully monitored. 
If this were to occur, there are procedures in place to treat the subject immediately during endoscopy.  
• 
Biopsies. There is the possibility of some hoarseness, sore throat, difficulty and/or pain in swallowing, 
bleeding or infection, as well as discomfort at the surgical site. One to two biopsies will be collected 
from LCE normal areas in the esophagus for the study procedure. This additional biopsy does not 
increase or change the risks due to biopsy collection. 
• 
Pregnancy. Insufficient information is available on the use of Proflavine in pregnancy. Drugs can have 
harmful effects on the fetus at any stage of pregnancy. A patient will not be enrolled in the study or 
have a standard of care endoscopy performed if they are pregnant. 
• 
Loss of Privacy. Subjects will be asked to give consent on the day of their procedure. Subjects will be 
taken to a private area to discuss the study information. All sensitive information will be requested 
from the subjects, and only what is required to perform a standard endoscopy. Subjects will be given 
a study ID number for all forms, images, and communications. All data will be removed of identifiers 
and coded. Source documents of all PHI will be redacted before being sent from outside sites for data 
monitoring/data entry in the database. All PHI collected on BCM subjects will be stored in locked 
cabinets or password-protected files/computers where only the PI and study coordinator can see the 
names. All case report forms will use the assigned subject ID. Since the subject participation is only 
for one visit, there will be limited opportunity for privacy interests to arise between study recruitment 
and the end of the study. The only extra privacy intrusion will be an additional phone call within 7 
days of the procedure to ensure that the subject has not suffered any adverse events. Only the study 
coordinator and/or the PI will contact the subject during the follow-up. Information about the study 
will only be discussed with the subject, and messages containing identifiers of the subject's 
participation will not be left on voice-mail messages.  
 
There are immediate, but very rare, risks of standard of care endoscopy procedure overall with or without 
the study procedure: 
 
• 
Bleeding. The risk of bleeding complications after an endoscopy is increased if the procedure involves 
removing a piece of tissue for testing (biopsy) or treating a digestive system problem. In rare cases, 
such bleeding may require a blood transfusion. 
• 
Infection. Most endoscopies consist of an examination and biopsy, and risk of infection is low. The 
risk of infection increases when additional procedures are performed as part of the standard of care 
endoscopy. Most infections are minor and can be treated with antibiotics. The study doctor may give 
the subject preventive antibiotics before their procedure if they are at higher risk of infection. 
• 
Aspiration. See above. 
• 
Biopsies: See above. 
• 
Tearing of the gastrointestinal tract. A tear in the subject’s esophagus or another part of their upper 
digestive tract may require hospitalization, and sometimes surgery to repair it. The risk of this 
complication is very low — it occurs in an estimated 1 of every 2,500 to 11,000 diagnostic upper 
endoscopies. The risk increases if additional procedures, such as dilation to widen their esophagus, 
are performed. 

Effectiveness, Efficiency, and Performance of a Mobile, Automated, Optical Biopsy Technology for Esophageal Cancer 
Screening: A Clinical Study in Brazil and the United States 
Version 2.0 
Protocol H-53483 
6 November 2025 
NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
8 
• 
A reaction to sedation or anesthesia. Upper endoscopy is usually performed with sedation or 
anesthesia. The type of anesthesia or sedation depends on the person and the reason for the 
procedure. There is a risk of a reaction to sedation or anesthesia, but the risk is low. 
 
Symptoms after a standard of care endoscopy procedure to look out for include:  
• 
Fever 
• 
Chest pain 
• 
Shortness of breath 
• 
Bloody, black or very dark colored stool 
• 
Difficulty swallowing 
• 
Severe or persistent abdominal pain 
• 
Vomiting, especially if your vomit is bloody or looks like coffee ground 
2.3.1.2 LONG-TERM RISKS 
There are no long-term risks associated with standard of care endoscopy procedures, and there are no 
known long-term risks of one-time exposure to proflavine. 
2.3.2 KNOWN POTENTIAL BENEFITS 
2.3.2.1 IMMEDIATE POTENTIAL BENEFITS 
Subjects may not directly benefit from participating in this research. However, the AI-mHRME may detect 
an area of neoplasia not detected by standard-of-care endoscopy and Lugol's chromoendoscopy. The 
results from the AI-mHRME and the pathology from the endoscopy and study procedures will allow study 
doctors and investigators to better understand the changes in the esophageal squamous cells. 
2.3.2.2 LONG-RANGE POTENTIAL BENEFITS 
Long-range potential benefits to the clinical study include a societal benefit. The potential societal benefit 
will be to help increase the specificity of Lugol's chromoendoscopy when combined with AI-mHRME, 
allowing for earlier detection of esophageal cancer or pre-cancerous lesions and quicker treatment time. 
This may potentially increase survival rates for esophageal cancer as well. Societal benefits will be lower 
endoscopy and screening costs, time saved, and quicker turnaround for treatment. 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS 
The incremental risks of proflavine and AI-mHRME added to the standard of care endoscopy with white 
light and Lugol's iodine are minimal. The principal investigator has had NO serious adverse events in >1000 
subjects imaged with the HRME and proflavine. No risks related to either proflavine or AI-mHRME have 
been noted. White light endoscopy is the standard of care, and all subjects will be undergoing this 
standard of care procedure so that ALL patients will be receiving (at minimum) the standard of care. 
 
 

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3 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
Primary 
 
To evaluate the specificity among novices using AI-
mHRME during esophageal cancer screening and 
surveillance. Our goal is to increase the specificity 
among novices using AI-mHRME without significant 
reduction in sensitivity. 
Specificity (SP) of AI-mHRME in novices  
Secondary 
 
 (A) To assess the diagnostic performance of AI-
mHRME; 
 
 
(B) To evaluate provider confidence (experts and 
novices) in clinically interpreting mHRME (pre- and 
post-use of AI-mHRME); 
 
(C) To assess the clinical impact following AI-mHRME;  
 
 
(D) To determine the diagnostic yield of AI-mHRME  
 
 
(E) To determine procedure efficiency of AI-mHRME, 
including subjects saved any biopsy and biopsy 
efficiency. 
(A) Sensitivity, specificity, positive predictive 
value, negative predictive value (SN, SP,PPV, 
NPV) of AI-mHRME;  
 
(B) Provider (experts and novices) reported 
confidence level (low or high) in pre- and 
post- use of AI-mHRME; 
 
(C) Change in clinical plan (biopsy vs. no 
biopsy vs. treat) post-AI mHRME; 
 
(D) Truly neoplastic biopsies/total biopsies 
obtained 
 
(E) Subjects saved any biopsy: number of 
patients correctly saved any biopsy;    
Biopsy efficiency: the total number of 
biopsies saved.  
4 
STUDY DESIGN 
4.1 
OVERALL DESIGN 
This is a single arm, single visit, non-randomized phase 2 study. We plan to enroll 200 participants in the 
USA (n=50) and Brazil (n=150). We will recruit persons at risk for ESCN undergoing a previously scheduled 
endoscopic screening and surveillance examination.   
 
Screening patients enrolled in this study are defined as patients at high risk of ESCN who have never 
undergone endoscopy. Surveillance patients enrolled in this study are defined as patients with known 
esophageal dysplasia but not known cancer. 
 
Both male and female patients will be enrolled in the clinical trial. ESCN typically develops over time and 
in individuals over the age of 40 and those with a longstanding history of smoking or alcohol usage. In a 
retrospective review of our institutional databases, the disease was not encountered in a pediatric 
population; hence, we will not enroll individuals less than 18 years of age. In the Esophageal AI-mHRME 
clinical trial, participation in the study will be a clinic visit, with a phone call 7 days after the visit for follow-
up. 

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4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
Selection of Control Group 
 
There is no control group in the study. However, all individuals for this study will undergoing standard-of-
care (SOC) endoscopy with Lugol’s chromoendoscopy (LCE) and artificial intelligence-based mobile high-
resolution microendoscope (AI-mHRME) imaging with proflavine hemisulfate. Subjects enrolled and 
imaged with AI-mHRME during SOC endoscopy with LCE will have biopsies collected from LCE abnormal 
areas and LCE normal areas, thereby serving as their own controls. This selection is based on the current 
clinical practice for esophageal squamous cell neoplasia (ESCN) screening and surveillance, which, despite 
high sensitivity (>95%), suffers from low specificity (<60%), leading to excessive false positives and 
unnecessary biopsies. By using this SOC approach as the control, we can directly compare the clinical 
impact and efficacy of the AI-mHRME in real-world settings. 
 
No placebo or historical control was chosen because (1) the ethical considerations surrounding the need 
for effective cancer screening methods in high-risk populations and (2) the availability of a well-
established, albeit suboptimal, standard screening approach. A placebo control would be inappropriate 
due to the established benefits of endoscopic screening, and historical controls may not account for 
evolving clinical practices and technological advancements. 
 
Study Design Justification 
 
The main hypothesis of the research study is that AI-mHRME will increase LCE accuracy. Additional 
exploratory hypotheses include that AI-mHRME will (1) increase AI-mHRME accuracy in novice 
endoscopists and be non-inferior to expert endoscopists, (2) increase user confidence among expert and 
novice endoscopists, and (3) increase LCE efficiency and impact by reducing biopsies and second 
procedures. 
 
To evaluate these hypotheses, we will conduct a single-arm, non-randomized, phase 2 study. We plan to 
enroll 200 participants across two sites: the USA (n=50) and Brazil (n=150). Participants will be individuals 
at risk for ESCN undergoing a previously scheduled endoscopic screening and surveillance examination. 
 
This design allows for direct assessment of AI-mHRME’s real-world performance in diverse populations 
while mitigating ethical concerns that would arise from withholding standard-of-care screening from high-
risk individuals. The observational structure ensures that AI-mHRME’s effectiveness can be evaluated 
without altering participants' clinical care. 
 
Potential Challenges with the Control Group 
 
The use of SOC endoscopy and normal biopsy collection as the control poses several known challenges: 
 
1. Variability in Operator Expertise: Diagnostic accuracy with LCE is highly dependent on the skill 
and experience of the endoscopist. This may introduce heterogeneity, particularly in resource-
limited settings where access to expert endoscopists is limited. 
 
2. Confounding by Inflammation: LCE is known to highlight inflammatory areas, leading to an 
increased rate of false positives. This inherent limitation of the control method may amplify the 
observed benefits of AI-mHRME but must be carefully considered in interpretation. 

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3. Potential for Verification Bias: Since biopsy decisions are influenced by endoscopists’ visual 
assessment, differences in biopsy rates between AI-mHRME and LCE could introduce bias in 
diagnostic yield comparisons. 
 
This study is designed to rigorously assess AI-mHRME’s ability to improve ESCN screening and surveillance 
by reducing unnecessary biopsies, increasing diagnostic yield, and enhancing clinician confidence. The 
within-subject comparator and phase 2 study design provide a robust framework for evaluating AI-
mHRME’s clinical impact while addressing potential limitations through careful study execution and 
stakeholder engagement. The findings will inform future implementation efforts, with implications for AI-
assisted cancer screening across diverse populations and healthcare settings. 
4.3 
JUSTIFICATION FOR DOSE 
Proflavine hemisulfate solution for optical imaging contains 0.01% (0.1 mg/mL) proflavine hemisulfate in 
water. The proflavine solution will be prepared in 10 mL of water and stored in a dispending syringe and 
amber-colored bag at 4°C. Proflavine solution is administered during the endoscopy procedure after the 
Lugol’s iodine has been sprayed and before the AI-mHRME device is used for imaging of the esophagus. 
The proflavine solution is dispensed into the esophagus by connecting it to a spray catheter in the biopsy 
channel of the endoscopy. Approximately 5-7 mL of the proflavine solution in the syringe will be sprayed 
in the esophagus. The planned maximum dosage of proflavine solution will be 10 mL, and it will be a one-
time dosage during the endoscopy procedure and study procedure.  
 
Proflavine solution will be sprayed using the spray catheter in the esophagus the same way that Lugol’s 
iodine is sprayed in the esophagus during standard of care endoscopy procedures. 
4.4 
END OF STUDY DEFINITION 
A participant is considered to have completed the study if they have completed all phases of the study 
including the last follow-up chart review on day 180 shown in the Schedule of Activities (SoA), Section 1.3. 
 
The end of the study is defined as completion of the last follow-up chart review shown in the SoA in the 
trial globally. 
5 
STUDY POPULATION 
5.1 
INCLUSION CRITERIA 
Patients will be eligible for the Esophageal AI-mHRME clinical trial using the following inclusion criteria: 
• 
Patients scheduled for endoscopy procedures at the following sites:  
o Baylor St. Luke’s Medical Center (BSLMC), Houston, Texas, US 
o Harris Health Systems Ben Taub General Hospital (BTH), Houston, Texas, US 
o Instituto do Câncer de Estado de Saõ Paulo (ICESP), Saõ Paulo, Saõ Paulo State, Brazil 
o Barretos Cancer Center/Hospital de Amor (BCC), Barretos, Saõ Paulo State, Brazil 
• 
Patients or their legally authorized representative must be informed of the investigational nature 
of this study and must sign and give written informed consent per institutional and federal 
guidelines; 
• 
Patients undergoing routine (standard of care) LCE screening for esophageal squamous cell 
carcinoma (ESCC) 

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o Patients with known history of head/neck squamous cancer (e.g., laryngeal and 
hypopharyngeal cancer, nasal cavity and paranasal sinus cancer, nasopharyngeal cancer, 
oral and oropharyngeal cancer, or salivary gland cancer) 
o Heavy smoking and/or alcohol use 
o Dietary or geographic risk factors for ESCC 
• 
Patients undergoing follow-up surveillance for ESCC (e.g., prior low-grade dysplasia or indefinite 
for dysplasia)  
• 
Patients are 18 years or older. 
• 
Patients who have never been enrolled in a study with AI-mHRME and proflavine hemisulfate. 
5.2 
EXCLUSION CRITERIA 
For the Esophageal AI-mHRME clinical study, patients will be ineligible using the following exclusion 
criteria: 
• 
Allergy or prior reaction to Proflavine or Iodine; 
• 
Current active esophageal cancer not amenable to endoscopic therapy; 
• 
The patient is unable to undergo routine endoscopy with biopsy; 
o Women who are pregnant or breastfeeding; 
o Prothrombin time (PT) greater than 50% of control; prothrombin time test (PTT) greater 
than 50 sec, or international normalized ratio (INR) greater than 2.0; 
o Inability to tolerate sedated upper endoscopy due to cardio-pulmonary instability or 
other significant medical issues; 
o Patients with known, untreated esophageal strictures, prior partial esophageal resection, 
or altered anatomy preventing passage of the endoscope; 
o Patients who have previously been enrolled in a study with AI-mHRME and proflavine 
hemisulfate. 
5.3 
LIFESTYLE CONSIDERATIONS 
Not applicable. 
5.4 
SCREEN FAILURES 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of a clinical 
reason in which they cannot undergo an endoscopy procedure at date of consent and enrollment may be 
rescreened if they are eligible for endoscopy at a later date.  
5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
All patients scheduled for standard-of-care (SOC) upper endoscopy will be screened for eligibility for the 
study at each clinic site and date. The research population will be identified from patients at Baylor St. 
Luke’s Medical Center (BSLMC) and at Ben Taub Hospital (BTH) by Dr. Mimi Tan in Houston, Texas; at 
Instituto do Câncer do Estado de São Paulo (ICESP)/Faculdade de Medicine by Dr. Fauze Maluf-Filho in São 
Paulo, and at Barretos Cancer Center (BCC)/Hospital de Amor by Dr. Elisa Ryoka Baba. Each patient will be 
given information regarding the study and will be given the appropriate amount of time to weigh the risks 
and benefits of the study carefully. If the patient agrees to consent to participate in the study, they will 
be counseled regarding all alternatives to study enrollment and regarding the right to withdraw consent 
at any time. In addition, the patient will be reassured that participation in the clinical trial will not affect 
future medical care. The consent form will be the only document linking the participant and the research, 
which will be filed in the subject's medical record. 

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In the US, screening will be performed through a secure electronic medical record system and in Brazil 
screening will be done during the scheduled visit for the SOC endoscopy procedure in the São Paulo clinic. 
The study investigators and staff will ensure that personal information is kept confidential. All participant 
information will be stored securely in locked file cabinets in areas with access limited to study staff. To 
maintain participant confidentiality, all reports, study data collection, and administrative forms will be 
identified only by a coded number. All local databases will be secured with password-protected access 
systems. Forms, lists, logbooks, appointment books, and any other listings that link participant ID numbers 
to other identifying information will be stored in a separate, locked file in an area with limited access. 
 
Since Drs. Tan, Maluf, and Baba are medical providers at BSLMC and BTH, ICESP, and BCC, respectively, 
the temporary access to patients' PHI to determine eligibility for the US and Brazil study sites does not 
constitute more than minimal risk. It will not adversely affect the privacy rights and welfare of the 
individuals covered by the waiver. 
 
Patients who fit inclusion criteria will be consented into the research study. Once the patient consents, 
they will be enrolled in the study. Patients who do not consent to the study will only have their names 
and demographic information recorded so that the research coordinators will not re-contact them. All this 
will be kept in a screening log that only the site PIs and site study staff have access and will not be shared 
outside of each study site.  
 
The study PIs anticipate a higher enrollment of men than women as esophageal squamous cell carcinoma 
is more prevalent among men compared to women. Additionally, every year there is a higher incidence 
of men with ESCC compared to women in both the US and Brazil. However, they are committed to making 
every effort to enroll as many women as possible while meeting the recruitment targets. Additionally, the 
study sites expect a high proportion of minorities to be enrolled due to the diverse racial and ethnic 
populations living near the sites, in particular at BTH, ICESP, and BCC. 
 
The study aims to enroll participants from diverse racial and ethnic backgrounds, reflecting the 
populations of the metropolitan areas where the study sites are located: BSLMC and BTH in Houston, 
Texas, ICESP in São Paulo, BCC in Barretos, Brazil. We anticipate a significant enrollment of individuals 
from Black, Hispanic/Latino, and mixed-race backgrounds. 
6 
STUDY INTERVENTION 
6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
6.1.1 STUDY INTERVENTION DESCRIPTION 
Proflavine Hemisulfate 
 
Proflavine (also known as proflavin, acridine-3,6-diamine, or 3,6-diaminoacridine) is an acridine derivative 
with bacteriostatic properties, used as a topical antiseptic in wound dressings and in umbilical cord care. 
As a fluorescent nucleic-acid binding dye, proflavine is an effective optical contrast agent for visualizing 
cell nuclei. Proflavine is the principal component of acriflavine which has been used for fluorescent 
imaging in the European, Asian and Australian gastrointestinal literature without any adverse effects 
noted.23,24 
 

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Proflavine hemisulfate salt hydrate is commercially available as a red/orange powder from chemical 
manufacturers and suppliers including Sigma-Aldrich (St. Louis, MO) and Santa Cruz Biotechnology, Inc. 
(Santa Cruz, CA). The pharmaceutical preparation of proflavine solution for optical imaging is a 
formulation containing 0.01% (0.1 mg/mL) proflavine hemisulfate in water. The resulting proflavine 
solution is a yellowish liquid. This is lower than the concentration of the proflavine component in 
commercial triple dye, 0.11% (w/v) [Kerr Triple Dye, VistaPharm]. The quantity of solution used for 
imaging is likely to be no greater than that used in neonatal care (0.65 ml per single-use swab). 
Investigational in vivo human studies of confocal microscopy for gastrointestinal cancer currently use 
topical acriflavine at 0.05% concentration.24 The additional exposure to light which will occur during 
imaging can also be compared to that received by newborn babies undergoing phototherapy for jaundice. 
The high-resolution fiber-optic microendoscope proposed for use here delivers 1.2 mW of 455 nm light to 
the tissue through a 0.8 mm diameter fiber-optic bundle, corresponding to an irradiance level of 240 
mW/cm2. The American Academy of Pediatrics defines intensive phototherapy as a spectral irradiance of 
at least 30 μW/cm2 per nanometer over the 430-490 nm spectral band, equivalent to a total irradiance of 
1.8 mW/cm2.25 Although the irradiance level is 133 times higher with the fiber microendoscope system, a 
typical 10-minute imaging session is 144 times shorter than a typical 24-hour (1440-minute) phototherapy 
incubation, leading to an approximately equivalent light dose in each scenario. 
 
Artificial Intelligence Mobile High-Resolution Microendoscope (AI-mHRME) 
 
The AI-mHRME is a fiber-optic fluorescence microscope intended for in vivo imaging of epithelial cell 
nuclei in mucosal tissues. The primary optical components of the AI-mHRME device are a blue LED (light-
emitting diode), excitation filter, dichroic mirror, objective lens, fiber-optic probe, tube lens, emission 
filter, and high-frame-rate camera sensor. The AI-mHRME system also includes a laptop computer and 
user interface/software. 
 
Illumination light from the blue LED light source passes through the excitation filter, reflects from the 
dichroic mirror, and is focused by the objective lens onto the proximal end of the fiber-optic probe. A 
fluorescent contrast agent (0.01% w/v proflavine solution) is applied topically to the tissue to be imaged, 
and the distal end of the fiber-optic probe is placed in gentle contact with the tissue surface. The 
illumination light passes through the fiber-optic probe and excites fluorescence, highlighting epithelial cell 
nuclei. The emitted fluorescent light is collected by the fiber-optic probe and transmitted back through 
the objective lens, dichroic mirror, emission filter, and tube lens to be imaged onto a high-frame-rate 
camera sensor. A live video feed is displayed in real time, showing epithelial cell nuclei as bright dots. The 
system has a circular field of view of approximately 800 μm diameter and lateral resolution of 
approximately 4 μm. Depending on the system configuration, individual images and/or video may be 
collected (with or without the use of a foot pedal) and may be quantitatively analyzed in real time by an 
automated algorithm or may be saved for later analysis. 
 
AI-mHRME Non-significant risk (NSR) justification 
 
In correspondence between Rice University and the FDA for the investigational device exemptions (IDE) 
for HRME on 20 Dec 2010, the following was issued in a letter from the FDA: 
FDA had determined that the use of HFR-HRME in proposed clinical investigations is a 
nonsignificant risk (NSR) device study because it does not meet the definition of a 
significant risk (SR) device under § 812.3(m) of the investigational device exemptions 

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(IDE) 
regulation 
(21 
CFR 
812, 
available 
on 
the 
internet 
at 
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/showCFR.cfm?CFRPart=81
2). 
An IDE application is not required to be submitted to, or approved by, FDA for a NSR 
study. A NSR study is, however, subject to the abbreviated requirements described in§ 
812.2(b) of the IDE regulation. The abbreviated requirements stipulate that the 
sponsor of the investigation must label the device in accordance with§ 812.5; obtain 
institutional review board approval of the investigation as a NSR study; ensure that 
each investigator obtains informed consent from each subject under the investigator's 
care; comply with the monitoring requirements of§ 812.46; maintain records required 
under§ 812.140(b)(4) and (5) and file the reports required under § 812.150(b)(1) 
through (3) and (5) through (10); and ensure that participating investigators maintain 
the records required by§ 812.140(a)(3)(i) and file the reports required under§ 
812.150(a)(l), (2), (5) and (7). 
Under the abbreviated IDE requirements, a sponsor must also comply with the 
prohibitions against promotion and other practices as identified in§ 812.7. According 
to this section of the regulation, the sponsor of a NSR study, investigator, or any person 
acting for or on behalf of the sponsor or investigator is prohibited from promoting or 
test marketing the investigational device until after FDA has approved the device for 
commercial distribution; commercializing the device by charging a price greater than 
that necessary to recover the cost of manufacture, research, development, and 
handling; unduly prolonging the investigation; and representing the investigational 
device as being safe or effective for the purposes for which it is being investigated. 
6.1.2 DOSING AND ADMINISTRATION 
Proflavine hemisulfate solution for optical imaging contains 0.01% (0.1 mg/mL) proflavine hemisulfate in 
water. The proflavine solution will be prepared in 10 mL of water and stored in a dispending syringe and 
amber-colored bag at 4 degrees C. Proflavine solution is administered during the endoscopy procedure 
after the Lugol’s iodine has been sprayed and before the AI-mHRME device is used for imaging of the 
esophagus. The proflavine solution is dispensed into the esophagus by connecting it to a spray catheter 
in the biopsy channel of the endoscopy. Approximately 5-7 mL of the proflavine solution in the syringe 
will be sprayed in the esophagus. The planned maximum dosage of proflavine solution will be 10 mL, and 
it will be a one-time dosage during the endoscopy procedure and study procedure. 
6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
Proflavine hemisulfate will be purchased by the principal investigator and research staff from Sigma-
Aldrich Inc. and distributed to the four study sites and their corresponding research pharmacies. The PI’s 
research coordinator (RC) will place the order with the vendor. Once the proflavine shipment arrives, the 
RC will coordinate with the study sites and research pharmacy for delivery of proflavine.  
 
For BSLMC and BTH in Houston, Texas, the RC will hand carry the bottle of proflavine to the Research 
Pharmacy at BSLMC and to the IDS at BTH. For ICESP and BCC, the RC will arrange with the coordinators 

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at ICESP and BCC to ship the proflavine bottles from Houston, Texas, to ICESP in São Paulo, Brazil. Both 
bottles will be shipped to ICESP, and ICESP will arrange for one bottle of proflavine powder will be 
delivered to BCC in Barretos, Brazil. 
 
Proflavine hemisulfate will be kept in the original bottle in powder form at each research pharmacy and 
prepared on an as-needed basis for the study procedures. The research pharmacists will monitor the initial 
amount of proflavine and how much has been used after each batch of proflavine syringes are made. 
Approximately 2-3 months before a year has passed from proflavine delivery and opening of the bottle at 
each research pharmacy, the pharmacists should reach out to the site RCs to request a new bottle of 
proflavine hemisulfate powder. The site RCs will inform the site PIs and they will determine to purchase 
additional bottles of proflavine.  
 
Any unused product, once a bottle of proflavine expires or is not used up by the end of the study period, 
will be disposed of according to manufacturer's protocols and the research pharmacy’s protocols.  
 
Waste treatment methods according to Safety Data Sheet from Sigma Aldrich Inc.: Waste material must 
be disposed of in accordance with the national and local regulations. Leave chemicals in original 
containers. No mixing with other waste. Handle uncleaned containers like the product itself. See 
www.retrologistik.com for processes regarding the return of chemicals and containers, or contact [Sigma 
Aldrich Inc.] there if you have further questions. 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
Manufacturer 
Sigma-Aldrich Inc. 
 
Formulation 
Proflavine hemisulphate salt hydrate 
3,6-Diaminoacridinehemisulfate salt 
C13H11N3 · 0.5 H2SO4 · xH2O 
 
Appearance 
Form: Powder 
Color: Faint Orange to Red-Brown to Brown 
 
Packaging 
Amber/brown glass bottle with a red plastic cap 
 
Labeling 
White sticker with compound name “Proflavine hemisulfate” and catalog number “P2508-10G.” 
6.2.3 PRODUCT STORAGE AND STABILITY 
According to the manufacturer Sigma Aldrich Inc., proflavine hemisulfate powder is stable for one year 
from the date of shipment from the manufacturer. Study staff and research pharmacists must take note 
of when the proflavine hemisulfate was shipped from the manufacturer, when it arrived at the study site, 
and when it was first opened in the pharmacy. In its powder form, proflavine hemisulfate is stored in an 
amber-colored glass bottle at room temperature.  
 

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Proflavine hemisulfate solution is stored at 4C and protected from light in an amber or light-blocking bag. 
It can be stored at the research pharmacy and must be kept cold during transport to the endoscopy suites 
(if the location of the endoscopy and the pharmacy are in two separate buildings), and then kept cold at 
4C in the medications fridge in the endoscopy suite until it is ready for use.  
 
The prepared proflavine hemisulfate solution is stable at 4C refrigeration for up to 14 days. After 14 days, 
if it is not used in the study procedure, the prepared proflavine solution must be discarded in biohazard 
waste in either the pharmacy or the endoscopy unit, if it was stored for use at the medication fridge in 
endoscopy. 
6.2.4 PREPARATION 
Preparation of Proflavine Hemisulfate at the Research Pharmacy at each study site:  
 
Reagents: 
1. Proflavine Hemisulfate in powder form 
2. Sterile water 
 
Equipment:  
1. Hot plate 
2. Magnetic stirrer 
3. Thermometer 
 
Supplies: 
1. Weight boat 
2. Scoop 
3. Sterile 10 mL/cc syringes 
 
Procedure: 
1. Open and weight out 10 mg of the Proflavine Hemisulfate powder stored at room temperature.  
2. Prepare a solution of 0.01% (w/v) proflavine hemisulfate by dissolving 10 mg of proflavine in 100 
mL of sterile water for injection. 
3. Heat the solution to 40 degrees C. Shake or vortex the solution until the proflavine is completely 
dissolved (about 15 minutes). 
4. Transfer 10 mL of the prepared solution to a syringe and place each syringe individually in an 
amber/brown bag. 
5. The solution should be stored at 4C and protected from light. 
6. The solution is stable for up to 14 days in refrigeration. 
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
There are no methods of randomization and blinding used in this study design. Research doctors and site 
PIs will know the assignment of study participants as this is a single arm study and all study participants 
will receive the intervention of HRME imaging and proflavine hemisulfate. 
6.4 
STUDY INTERVENTION COMPLIANCE 
Study intervention compliance will be assessed on a quarterly basis. To assess study intervention 
compliance, the site RCs will complete the Case Report Form (CRF) section on HRME Procedure 

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completion. If HRME procedure was not completed, then it will be documented on the CRF if there was a 
clinical reason or technical reason for incomplete HRME procedure. If there are technical reasons, those 
will be used to calculate study intervention compliance. 
6.5 
CONCOMITANT THERAPY 
Not applicable. 
6.5.1 RESCUE MEDICINE 
Not applicable. 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT DISCONTINUATION OR 
WITHDRAWAL 
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
Upon completion of the study imaging and endoscopy procedure, subjects will be contacted to screen for 
symptoms and adverse events after 7 days from the endoscopy procedure. Adverse events or serious 
adverse events that occur during the follow-up period will be recorded regardless of relatedness to the 
study procedure. The follow-up will be conducted by a phone call; if clinically indicated, a clinic visit should 
be performed along with relevant lab work. 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
Participants are free to withdraw from participation in the study at any time upon request. 
 
An investigator may discontinue or withdraw a participant from the study for the following reasons: 
• 
If the patient is pregnant. 
• 
If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
• 
If the participant is unable to receive proflavine hemisulfate and HRME during endoscopy 
procedure. 
 
The reason for participant discontinuation or withdrawal from the study will be recorded on the CRF. 
Participants who sign the informed consent form but do not receive the study intervention (proflavine 
and HRME) may be re-scheduled at a later time depending on inclusion and exclusion criteria.  
7.3 
LOST TO FOLLOW-UP 
This is a single-visit study. A participant who completed all study procedures on Day 0 will be considered 
lost to follow-up if they cannot be contacted via phone call for the Day 7 follow-up symptom data 
collection and adverse event reporting.  
 
The following actions must be taken if a participant fails to be contacted after the study procedure: 
• 
The RCs will attempt to contact the participant up to three (3) times. 
• 
Before a participant is deemed lost to follow-up, the investigator or designee will make every 
effort to regain contact with the participant (where possible, 3 telephone calls and, if necessary, 
a certified letter to the participant’s last known mailing address or local equivalent methods). 
These contact attempts should be documented in the participant’s medical record or study file.  

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• 
Should the participant continue to be unreachable on Day 7 during the follow-up phone call, they 
will be considered lost to follow-up, they are not withdrawn from the study.  In such cases, the 
participant who is lost to follow-up will have their medical chart reviewed at Day 180. 
8 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
EFFICACY ASSESSMENTS 
For enrolled subjects, data will be collected via medical record review, including review of pathology for 
any previous upper endoscopy procedures and any prior treatment for esophageal pre-cancer or cancer. 
After six months of completing the endoscopy and HRME with proflavine study procedure, subjects will 
have their medical record reviewed for any follow-up standard of care endoscopy procedures to 
determine treatment, if any, and if pathology was done on any biopsies or specimens collected during 
that subsequent procedure. 
 
Survey and demographic data will be collected for all patients via interview, including demographics; 
medical history; tobacco and alcohol use; previous endoscopy procedures and corresponding pathology 
results; previous treatments for esophageal pre-cancer or cancer; and baseline symptoms prior to the 
current endoscopy procedure with HRME and proflavine. 
 
During the endoscopy procedure, the study clinician will perform the standard of care endoscopy. The RC 
will record the start and end time of the entire endoscopy procedure, and the white light endoscopy 
features—level of gastroesophageal junction, presence and grade of esophagitis; and number of visible 
lesions (ulcers, nodules, and/or masses).  
 
During the standard of care endoscopy, the study clinician will use NBI to assess the esophagus for any 
abnormal areas. If they observe any abnormal areas, for each area the RC will record the level and 
quadrant; if it is a visible lesion (ulcer or nodule), size and Paris classification; the study clinician’s read of 
the abnormal area (non-neoplastic or neoplastic); the study clinician’s confidence in their read (low or 
high confidence); the study clinician’s theoretical plan (no biopsy, biopsy, ablate, endoscopy mucosal 
resection [EMR] or endoscopic submucosal dissection [ESD]); and start and end time of NBI. Once 
recorded for all abnormal areas under NBI, the study clinician moves on to the do same assessment for 
LCE with Lugol’s iodine. The RC will record the read, confidence, and plan for all Lugol’s abnormal areas, 
and the start and end time of LCE. Once the study clinician has completed LCE assessment, they move on 
to the study procedure with HRME and proflavine. The RC records the amount of proflavine used to spray 
in the esophagus, and the study clinician observes all Lugol’s abnormal areas and at least one Lugol’s 
normal area with HRME. The RC records the study clinician’s read, confidence, and plan. Afterwards, the 
RC saves the HRME image and records the image number, score and read. After the HRME score is 
generated, the RC records the study clinician’s read, confidence, and plan post HRME score. This is 
repeated for 1-2 Lugol’s normal areas with HRME imagining and data recording. The RC will also collect 
the start and end time of all the HRME imaging. Lastly, the study clinician will collect biopsies from the 
Lugol’s abnormal and normal areas that were imaged with HRME, and the RC will record the biopsy jar 
label and start and end time of biopsy collection.   
 
Pathology of esophageal biopsy specimens will be graded by Drs. Rosen, Sobroza, and Reis at BSLMC/BTH, 
ICESP, and BCC, respectively. Dr. Rosen will also serve as the pathologist for central pathology review. 
Non-neoplastic biopsies are those biopsies with a diagnosis of normal, esophagitis, and/or low-grade 

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dysplasia. Neoplastic biopsies are those biopsies with a pathology read of medium-grade dysplasia, high-
grade dysplasia, or cancerous.  
 
This study has study procedures in a clinic-visit. Participants will be called on day 7 after the procedure to 
ask about symptoms and adverse events. To ensure that we can contact the patients by phone, we will 
request at least 2 phone numbers from each patient, their address as 2 phone numbers and addresses 
from emergency contacts. 
8.2 
SAFETY AND OTHER ASSESSMENTS 
Upon completion of the study imaging, subjects will be contacted to screen for adverse events after 7 
days from the endoscopy procedure. Patients with abnormal clinical findings will be followed until the 
condition resolves or stabilizes. Adverse events or serious adverse events that occur during the follow-up 
period will be recorded regardless of relatedness to the study procedure. The safety follow-up may be 
conducted by a phone visit; if clinically indicated, a clinic visit should be performed along with relevant lab 
work. 
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
We will use Common Terminology Criteria for Adverse Events (AEs) v5.0. Serious adverse events (SAE) will 
count as Grade 3 (Severe or Medically Significant, but not Immediately Life Threatening: Hospitalization 
or Prolongation of Hospitalization Indicated; Disabling; Limiting Self Care ADL), Grade 4 (Life-threatening 
consequences; urgent intervention indicated), or Grade 5 (Death related to AE). 
 
Upon completion of the study imaging, subjects will be contacted to screen for adverse events after 7 
days from the endoscopy procedure. Patients with abnormal clinical findings will be followed until the 
condition resolves or stabilizes. Only AEs or SAEs related to the study procedure that occur during the 
follow-up period will be recorded. The safety follow-up may be conducted by a phone visit; if clinically 
indicated, a clinic visit should be performed along with relevant lab work. 
 
We anticipate most AE/SAEs will be related to the upper endoscopy procedure rather the HRME and 
proflavine hemisulfate. 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
An AE or suspected AE is considered "serious" if, in the view of either the investigator or sponsor, it results 
in any of the following outcomes: death, a life-threatening adverse event, inpatient hospitalization or 
prolongation of existing hospitalization, a persistent or significant incapacity or substantial disruption of 
the ability to conduct normal life functions. Important medical events that may not result in death, be life-
threatening, or require hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the participant and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. Examples of such medical events include allergic 
reaction to proflavine hemisulfate requiring intensive treatment in an emergency room or at home, severe 
aspiration of fluids during endoscopy procedure that requires hospitalization in the ICU, or endoscopic 
perforation and/or uncontrolled bleeding from endoscopy procedure that requires hospitalization and 
blood.  

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8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.3.3.1 SEVERITY OF EVENT 
We will use the Common Terminology Criteria for Adverse Events (AEs) v5.0 definitions for severity of 
events. 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
All AEs must have their relationship to study intervention assessed by the clinician who examines and 
evaluates the participant based on temporal relationship and his/her clinical judgment. The degree of 
certainty about causality will be graded using the categories below. In a clinical trial, the study product 
must always be suspect. Only AEs that are deemed related to the study procedures will be reported. 
 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible 
contributing factors can be ruled out. The clinical event, including an abnormal laboratory test 
result, occurs in a plausible time relationship to study intervention administration and cannot be 
explained by concurrent disease or other drugs or chemicals. The response to withdrawal of the 
study intervention (dechallenge) should be clinically plausible. The event must be 
pharmacologically or phenomenologically definitive, with use of a satisfactory rechallenge 
procedure if necessary. 
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence of other 
factors is unlikely. The clinical event, including an abnormal laboratory test result, occurs within a 
reasonable time after administration of the study intervention, is unlikely to be attributed to 
concurrent disease or other drugs or chemicals, and follows a clinically reasonable response on 
withdrawal (dechallenge). Rechallenge information is not required to fulfill this definition. 
• 
Possibly Related – There is some evidence to suggest a causal relationship (e.g., the event 
occurred within a reasonable time after administration of the trial medication). However, other 
factors may have contributed to the event (e.g., the participant’s clinical condition, other 
concomitant events). Although an AE may rate only as “possibly related” soon after discovery, it 
can be flagged as requiring more information and later be upgraded to “probably related” or 
“definitely related”, as appropriate. 
• 
Unlikely to be related – A clinical event, including an abnormal laboratory test result, whose 
temporal relationship to study intervention administration makes a causal relationship 
improbable (e.g., the event did not occur within a reasonable time after administration of the 
study intervention) and in which other drugs or chemicals or underlying disease provides plausible 
explanations (e.g., the participant’s clinical condition, other concomitant treatments). 
• 
Not Related – The AE is completely independent of study intervention administration, and/or 
evidence exists that the event is definitely related to another etiology. There must be an 
alternative, definitive etiology documented by the clinician. 
8.3.3.3 EXPECTEDNESS 
The site PI and the coordinating center PI will be responsible for determining whether an adverse event 
(AE) is expected or unexpected. An AE will be considered unexpected if the nature, severity, or frequency 
of the event is not consistent with the risk information previously described for the study intervention. 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 

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The occurrence of an AE or SAE may come to the attention of study personnel during study visits and 
interviews of a study participant presenting for medical care, or upon review by a study monitor. 
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured on the 
appropriate CRF. Information to be collected includes event description, time of onset, clinician’s 
assessment of severity, relationship to study product (assessed only by those with the training and 
authority to make a diagnosis), and time of resolution/stabilization of the event. All AEs occurring while 
on study must be documented appropriately regardless of relationship. All AEs will be followed to 
adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be considered as 
baseline and not reported as an AE. However, if the study participant’s condition deteriorates at any time 
during the study, it will be recorded as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event 
at each level of severity to be performed. AEs characterized as intermittent require documentation of 
onset and duration of each episode. 
 
RCs will record all reportable events with start dates occurring any time after the study procedures with 
HRME and proflavine are completed on Day 0.  During the Day 7 phone call, RCs will inquire about the 
occurrence of AE/SAEs. Events will be followed for outcome information until resolution or stabilization. 
8.3.5 ADVERSE EVENT REPORTING  
The PI must report any study related AE to the BCM IRB within 5 business days. Study related AEs will be 
reported to the IRB annually at renewal. AEs will be reviewed annually by the IRB. Any study related AE 
that is reportable to IRB will also be reported to the DLDCCC Data Review Committee (DRC) via the Patient 
Safety Officer at dldcc-pso@bcm.edu.  
 
Principal investigators must report to the BCM IRB and the external IRB of Record (if applicable according 
to procedure) as soon as possible, but in all cases within 5 business days of any of the following events: 
1) Event (including but not limited to on-site and off-site adverse event reports, injuries, side effects, 
breaches of confidentiality, deaths, or other problems) that occurs any time during or after the 
research study, which in the opinion of the principal investigator meets all the elements a) 
through c) below: 
a. Suggests that the research places one or more participants or others at a greater risk of 
harm (including physical, psychological, economic, or social harm) than was previously 
known or recognized. A new or increased risk may be defined as one that requires some 
action (e.g., requiring a significant and usually safety-related, change in the protocol such 
as revising inclusion/exclusion criteria or including a new monitoring requirement, 
informed consent, or investigator’s brochure, modification of the consent process, or 
informing participants.) 
b. Unexpected/Unanticipated (in terms of nature, severity, or frequency given: 
i. The research procedures that are described in the protocol-related documents, 
such as the IRB-approved research protocol and informed consent document; 
and, 
c. The characteristics of the subject population being studied. Related or possibly related to 
the participation in the research procedures: 

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i. Possibly related means there is a reasonable possibility that the incident, 
experience, or outcome may have been caused by the procedures involved in the 
research 
ii. An event is “related to the research procedures” if in the opinion of the principal 
investigator, it was more likely than not to be caused by the research procedures 
or if it is more likely than not that the event affects the rights and welfare of 
current participants 
d. Note: If an event, in the opinion of the principal investigator, does not meet ALL of the 
elements a) through c) above, the PI is not required to make a prompt report to the IRB. 
However, such events may require reporting to the sponsor. 
2) Changes made to the research protocol without prior IRB review to eliminate apparent immediate 
harm to a research participant(s) 
a. Note: For protocol deviations that do not require prompt reporting, at time of continuing 
review the investigator will inform the IRB of its own quality monitoring processes by 
which deviations were identified, and process changes to prevent unintended variances. 
3) Other unanticipated event, incident, or problem that is related to the research and that indicates 
that participants or others might be at new or increased risks: 
a. Any event that requires prompt reporting to the IRB according to the research protocol 
or plan or the sponsor 
b. Any accidental or unintentional change to the IRB-approved research protocol (PI self-
report of non-compliance) or plan that involved risks or has the potential to recur. 
c. Any publication in the literature, safety monitoring report, interim result, or other finding 
that indicates an unexpected change to the risks or potential benefits of the research. For 
example: 
i. An interim analysis indicates that participants have a lower rate of response to 
treatment than initially expected 
ii. Safety monitoring indicates that a particular side effect is more severe, or more 
frequent than initially expected 
iii. A paper is published from another study that shows that an arm of your research 
study is of no therapeutic value 
4) Any complaint of a participant that indicates unanticipated risk or that cannot be resolved by the 
research team 
5) Protocol violation (meaning an accidental or unintentional change to the IRB approved protocol) 
that placed one or more participants at increased risk, or has the potential to occur again 
6) Any instance of non-compliance including PI self-reports 
7) Any suspension or termination of research approval 
8) Unanticipated adverse device effect (Any serious adverse effect on health or safety or any life-
threatening problem or death caused by, or associated with, a device, if that effect, problem, or 
death was not previously identified in nature, severity, or degree of incidence in the 
investigational plan or application (including a supplementary plan or application), or any other 
unanticipated serious problem associated with a device that relates to the rights, safety, or 
welfare of subjects.) 
9) Unauthorized disclosure of Protected Health Information (PHI) or breach of electronic security 
(these events should concurrently be reported to the BCM Privacy Officer and IT Security) 
 
Any AE that is reportable to the BCM IRB must also be reported by the BCM PI to the FDA via safety reports 
and in the annual FDA IND report. Unexpected fatal or life-threatening adverse drug experiences will be 

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reported within 7 calendar days. Serious and unexpected adverse drug experiences will be reported within 
15 calendar days. 
8.3.6 SERIOUS ADVERSE EVENT REPORTING 
The PI and study team will monitor 100% of SAEs. SAEs in the study will use the same guidelines for 
reporting as AEs outlined above. 
8.3.7 REPORTING EVENTS TO PARTICIPANTS 
Not applicable. 
8.3.8 EVENTS OF SPECIAL INTEREST 
Not applicable 
8.3.9 REPORTING OF PREGNANCY 
Not applicable. This study will not enroll people who are pregnant. 
8.4 
UNANTICIPATED PROBLEMS 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
The Office for Human Research Protections (OHRP) considers UP involving risks to participants or others 
to include, in general, any incident, experience, or outcome that meets all of the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the IRB-approved research protocol and 
informed consent document; and (b) the characteristics of the participant population being 
studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
This definition could include an unanticipated adverse device effect, any serious adverse effect on health 
or safety or any life-threatening problem or death caused by, or associated with, a device, if that effect, 
problem, or death was not previously identified in nature, severity, or degree of incidence in the 
investigational plan or application (including a supplementary plan or application), or any other 
unanticipated serious problem associated with a device that relates to the rights, safety, or welfare of 
subjects (21 CFR 812.3(s)). 
8.4.2  UNANTICIPATED PROBLEM REPORTING 
The investigator will report UPs to the reviewing IRB and to the Data Coordinating Center (DCC)/lead 
principal investigator (PI). The UP report will include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 

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• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP;  
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:  
 
• 
UPs that are SAEs will be reported to the IRB and to the DCC/study sponsor within <insert timeline 
in accordance with policy> of the investigator becoming aware of the event.  
• 
Any other UP will be reported to the IRB and to the DCC/study sponsor within <insert timeline in 
accordance with policy> of the investigator becoming aware of the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the OHRP within 7 
days of the IRB’s receipt of the report of the problem from the investigator. 
 
An investigator shall submit to the sponsor and to the reviewing IRB a report of any unanticipated adverse 
device effect occurring during an investigation as soon as possible, but in no event later than 10 working 
days after the investigator first learns of the effect (21 CFR 812.150(a)(1)), A sponsor who conducts an 
evaluation of an unanticipated adverse device effect under 812.46(b) shall report the results of such 
evaluation to the FDA and to all reviewing IRB's and participating investigators within 10 working days 
after the sponsor first receives notice of the effect. Thereafter the sponsor shall submit such additional 
reports concerning the effect as FDA requests (21 CFR 812.150(b)(1)). 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS 
Not applicable. 
9 
STATISTICAL CONSIDERATIONS 
9.1 
STATISTICAL HYPOTHESES 
This is a multi-center, single-arm, non-randomized, phase 2 study designed to evaluate the use of AI-
mHRME as a diagnostic aid in high risk patients undergoing screening or surveillance for esophageal 
cancer. Our goal is to enhance the specificity using AI-mHRME, particularly among novices, and to 
determine the accuracy, impact and effectiveness of AI-mHRME. 
9.2 
SAMPLE SIZE DETERMINATION 
We plan to enroll 200 patients across the USA and Brazil sites.  The expected prevalence of neoplasia is 
8% in the screening population and 50% in the surveillance population; thus, among 200 subjects (140 in 
screening and 60 in surveillance), we expect 158 subjects enrolled in the study with no evidence of biopsy-
confirmed neoplasia. Assuming 80% of endoscopists are novices, 126 patients without neoplasia will be 
examined by novice endoscopists. The sample size of 126 pairs of novice interpretations pre- and post-AI-
mHRME will provide 90% power to detect an improvement in the specificity of 20% (80% vs. 60%) by 
McNemar's test of equality with 0.5 discordant pairs and a 5% two-sided significance level. 
 
Clinical impact is a key of AI-mHRME. In the Brazil trial, native endoscopists chose to “biopsy or treat” for 
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the proportion of non-neoplasia subjects recommended for biopsy/treat will reduce to 55% after using 
AI-mHRME software algorithm. The study will have 95% power to detect the difference of 15% in pre and 
post plans (70% vs 55%) at a 5% two-sided significance level. 
9.2.1 ANALYSIS OF THE PRIMARY ENDPOINT 
The primary endpoint is specificity of AI-mHRME in novices. Specificity will be calculated for novices pre- 
and post- AI-mHRME assessments with 95% confidence intervals. The paired data will be compared using 
McNemar’s test to assess difference in specificity.  
9.2.2 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
The secondary endpoints include the following: 
 
1) Performance Characteristics, including sensitivity, specificity, positive and negative predictive value 
(SN, SP, PPV and NPV) will be estimated for endoscopist’s interpretations and AI-mHRME along with 95% 
confidence intervals for overall and by clinician level.  These measures will be compared to gold standard 
pathology.  Analysis will be performed on both a per-patient and per-biopsy basis. 
 
2) Clinician Confidence level pre- and post- use of AI-mHRME will be recorded. Changes in confidence 
level will be summarized for all users (experts and novices) and by clinical level with proper descriptive 
statistics and presented in cross tables. 
 
3) Clinical Impact will be estimated as the percentage of patients with a correct change in clinical plan 
(biopsy vs. no biopsy vs. treat) along with 95% confidence intervals post-AI-mHRME for all users (experts 
and novices). Additionally, changes in clinical plan at pre and post- AI-mHRME will be presented in cross 
tables.  
 
4) Diagnostic Yield will be calculated as the number of biopsies with neoplastic pathology divided  
by the total number of biopsies obtained along with 95% confidence intervals.  
 
5) Procedure Efficiency will be assessed by subjects saved any biopsy and biopsy efficiency. 
  
a) Subjects saved any biopsy will be assessed by the number of patients whose biopsies are cor-
rectly changed from neoplastic (positive) to non-neoplastic (negative), with each biopsy showing 
negative pathology.  
 
b) Biopsy efficiency will be determined by the number of biopsies that can be potentially avoided as 
a result of correctly changing from neoplastic to non-neoplastic with the addition of AI-mHRME. 
9.2.3 SAFETY ANALYSES 
All patients who start study procedures will be included in the safety analysis. Safety data will be assessed 
through descriptive summaries of AEs. AEs will be tabulated by body system, preferred term, severity and 
relationship to study procedures. All AE data will be listed by patient to evaluate severity and causality. 
9.2.4 PLANNED INTERIM ANALYSES 
No interim analysis is planned. 

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9.2.5 SUB-GROUP ANALYSES 
No sub-group analyses are planned. 
9.3 
POPULATIONS FOR ANALYSES 
Safety population includes all patients who start any study procedures regardless of  
completeness.  
 
Accuracy and effectiveness population will be used for evaluating diagnostic performance, diagnostic 
yield, and procedure efficiency.  
 
Patient-level population includes all patients who complete the AI-mHRME and have both inter-
pretations and corresponding gold standard histopathology results available.  
 
Biopsy-level population includes all biopsies from patients who complete the AI-mHRME and 
have both interpretations and corresponding gold standard histopathology results available.  
 
Confidence level population includes biopsies from patients who complete the AI-mHRME and have con-
fidence level collected.  
 
Clinical impact population includes patients who complete the AI-mHRME, have both interpretations and 
corresponding gold standard histopathology results available and clinicians make a treatment plan (no 
biopsy, biopsy or treat). 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
10.1.1 INFORMED CONSENT PROCESS 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
Consent forms describing in detail the study intervention, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study intervention.  The following consent materials are submitted with this 
protocol: H-53483 Consent Form. 
10.1.1.2 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. Consent forms will be IRB-approved and 
the participant will be asked to read and review the document. The investigator or research staff will 
explain the research study to the participant and answer any questions that may arise. A verbal 
explanation will be provided in terms suited to the participant’s 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 family or surrogates or think about 

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it prior to agreeing to participate. The participant will sign the informed consent document prior to any 
procedures being done specifically for the study. Participants must be informed that participation is 
voluntary and that they may withdraw from the study at any time, without prejudice. A copy of the 
informed consent document will be given to the participants for their records. The informed consent 
process will be conducted and documented in the source document (including the date), and the form 
signed, before the participant undergoes any study-specific procedures. 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. 
 
The consent process will be conducted in the patient’s preferred language. There is a full-length consent 
form in English, Spanish, and Portuguese. To facilitate the consent process and discussions, medical 
interpreters are available to assist the research staff and patients 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or termination, will be provided 
by the suspending or terminating party to the investigator, funding agency, the IND sponsor and 
regulatory authorities. If the study is prematurely terminated or suspended, the PI will promptly inform 
the IRB, and sponsor and will provide the reason(s) for the termination or suspension. 
 
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping    
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, and 
satisfy the sponsor, IRB and/or FDA. 
10.1.3 CONFIDENTIALITY AND PRIVACY 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, their staff, 
and the sponsor(s) and their interventions. This confidentiality is extended to cover testing of biological 
samples and genetic tests 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.  
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the IRB, regulatory 
agencies or pharmaceutical company 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. 

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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 the reviewing IRB, Institutional policies, or sponsor requirements. 
 
Study participant research data, which is for purposes of statistical analysis and scientific reporting, will 
be transmitted to and stored at Baylor College of Medicine, the coordinating center. 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 Baylor College of Medicine 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 
Baylor College of Medicine. 
 
Certificate of Confidentiality (COC) 
 
To further protect the privacy of study participants, a COC will be issued by the NIH. This certificate 
protects identifiable research information from forced disclosure. It allows the investigator and others 
who have access to research records to refuse to disclose identifying information on research 
participation in any civil, criminal, administrative, legislative, or other proceeding, whether at the federal, 
state, or local level. By protecting researchers and institutions from being compelled to disclose 
information that would identify research participants, COC help achieve the research objectives and 
promote participation in studies by helping assure confidentiality and privacy to participants. 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA 
Data collected for this study will be analyzed and stored at Baylor College of Medicine. 
 
When the study is completed, access to study data will be provided through Baylor College of Medicine. 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
Principal Investigator 
Site PI - ICESP 
Site PI – Barretos 
Mimi Tan, MD, MPH 
Fauze Maluf-Filho, MD 
Elisa Ryoka Baba, MD, PhD 
Baylor College of Medicine  
Instituto do Cancer do Estado 
de Sao Paulo 
Barretos Cancer Hospital / 
Hospital de Amor 
Attn: Arlene Zamora, 
Gastroenterology, Ben Taub 
Hospital, 1504 Taub Loop, 
Houston, TX 77030 
Av. Dr. Arnaldo, 251 
São Paulo 
Brazil 
01246-000 
Rua Anterior Duarte Villela, 
1331 
Bairro Dr. Paulo Prata 
Barretos São Paulo 
Brazil 
+1 713-873-3560 
+55 11991919014 
+55 (11) 98501-9190 
mc2@bcm.edu 
fauze.maluf@terra.com.br  
erbaba@uol.com.br  
 
In Brazil, the highest ethical authority for research involving human subjects is the National Research 
Ethics Committee (REC, Conep). Established in 1996, it is a central regulatory committee which 
coordinates a communication network of 836 institutional RECs. Conep is tasked with defining operational 
criteria for local RECs and setting all standards that guide the development of research involving human 
subjects in Brazil. 
 

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Currently, the entire ethical review process of any research involving human beings in Brazil is carried out 
within a digital platform called Plataforma Brasil (https://plataformabrasil.saude.gov.br/login.jsf). The 
registration and management of investigators, registration of research projects, and upload of all 
documents related to the research project are done on the platform, which creates a specific, 
individualized identifier for each project. The project evaluation process itself is also fully remote, with 
opinions based on the evaluation meetings held at the local RECs. 
 
The ethical approval for this clinical trial was first submitted to ICESP, and once approved, was reviewed 
by the National Body. After the final approval from the National Body, the clinical trial ethics submission 
was sent to Barretos Cancer Hospital for an expedited approval process as institutions can rely on final 
approvals from other institutions such as ICESP. 
10.1.6 SAFETY OVERSIGHT 
Safety oversight will be under the direction of an Independent Safety Monitor at the University of 
Michigan, Kirsten Tuck, for the data collection, consent, and enrollment at Baylor College of Medicine 
(BSLMC and Ben Taub Hospital).  For data collection done at ICESP and Barretos Cancer Hospital, the BBCM 
research staff will provide monitoring and oversight.  
10.1.7 CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants 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 ICH GCP, and with 
applicable regulatory requirement(s).  
 
• 
Monitoring for this study for the Brazil sites will be performed by the Principal Investigator’s, 
Mimi Tan, research staff at Baylor College of Medicine.  
• 
Monitoring for this study for the BCM sites (BSLMC and Ben Taub) will be done by an outside 
independent monitor. 
• 
Monitoring will be done by Dr. Mimi Tan’s research team on site once a year and centralized at 
BCM research office using electronic/scanned CRFs. Monitoring will be done throughout the 
study at 25% enrollment, 50% enrollment, 75% enrollment, and 100% enrollment of study 
participants. The monitoring will be comprehensive, with 100% of the data and consent forms 
monitored. The BCM research team will prepare a monitoring report after each monitoring 
session and provide it to the PI and local PIs. 
• 
Independent audits may be conducted by the FDA to ensure monitoring practices are performed 
consistently across all participating sites. 
10.1.8 QUALITY ASSURANCE (QA) AND QUALITY CONTROL (QC) 
Each clinical site will perform internal quality management of study conduct, data collection, 
documentation and completion.  An individualized quality management plan will be developed to describe 
a site’s quality management. 
 
Quality control (QC) procedures will be implemented beginning with the data entry system and data QC 
checks that will be run on the database will be generated. Any missing data or data anomalies will be 
communicated to the site(s) for clarification/resolution. 
 

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Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is 
conducted and data are generated and biological specimens are collected, documented (recorded), and 
reported in compliance with the protocol, ICH GCP, and 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. 
10.1.9 DATA HANDLING AND RECORD KEEPING 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the site 
investigator. The investigator 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.   
 
Hardcopies of the study visit worksheets will be provided for use as source document worksheets for 
recording data for each participant enrolled in the study. Data recorded in the electronic case report form 
(eCRF) derived from source documents should be consistent with the data recorded on the source 
documents.  
 
Clinical data (including AEs, concomitant medications, and expected adverse reactions data) and clinical 
laboratory data will be entered into Advarra OnCore, a 21 CFR Part 11-compliant data capture system 
provided by the Baylor College of Medicine. 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. 
10.1.9.2 STUDY RECORDS RETENTION 
Study documents should be retained for a minimum of 2 years after the last approval of a marketing 
application in an ICH region and until there are no pending or contemplated marketing applications in an 
ICH region or until at least 2 years have elapsed since the formal discontinuation of clinical development 
of the study intervention. These documents should be retained for a longer period, however, if required 
by local regulations. No records will be destroyed without the written consent of the sponsor, if applicable. 
It is the responsibility of the sponsor to inform the investigator when these documents no longer need to 
be retained. 
10.1.10 
PROTOCOL DEVIATIONS 
A protocol deviation is any noncompliance with the clinical trial protocol, ICH GCP, or Manual of 
Procedures (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 GCP:  

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• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance (QA) and Quality Control (QC), section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of the site investigator to use continuous vigilance to identify and report deviations 
within 5 working days of identification of the protocol deviation.  All deviations must be addressed in 
study source documents, reported to NCI Program Official and Baylor College of Medicine. Protocol 
deviations must be sent to the reviewing IRB per their policies. The site investigator is responsible for 
knowing and adhering to the reviewing IRB requirements. Further details about the handling of protocol 
deviations will be included in the MOP. 
10.1.11 
PUBLICATION AND DATA SHARING POLICY 
This study will be conducted in accordance with the following publication and data sharing policies and 
regulations: 
 
NIH Public Access Policy, which ensures that the public has access to the published results of NIH funded 
research. It requires scientists to submit final peer-reviewed journal manuscripts that arise from NIH funds 
to the digital archive PubMed Central upon acceptance for publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded 
Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As 
such, this trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer-reviewed 
journals.  Data from this study may be requested from other researchers 10 years after the completion of 
the primary endpoint by contacting Mimi Tan, Baylor College of Medicine. 
10.1.12 
CONFLICT OF INTEREST POLICY 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical. Therefore, any actual conflict of interest of people who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
people 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 design and conduct of this trial.  The study leadership in 
conjunction with the NCI has established policies and procedures for all study group members to disclose 
all conflicts of interest and establish a mechanism for the management of all reported dualities of interest. 
10.2 ADDITIONAL CONSIDERATIONS 
Not applicable. 
 

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10.3 ABBREVIATIONS 
ADL 
Activities Daily Living 
AE 
Adverse Event 
AI 
Artificial intelligence 
AI-mHRME 
Artificial intelligence mobile High resolution microendoscope 
ANCOVA 
Analysis of Covariance 
BCC 
Barretos Cancer Center/Hospital de Amor 
BSLMC 
Baylor St. Luke’s Medical Center 
BTH 
Ben Taub Hospital 
CFR 
Code of Federal Regulations 
COC 
Certificate of Confidentiality 
CONSORT 
Consolidated Standards of Reporting Trials 
CRF 
Case Report Form 
DCC 
Data Coordinating Center 
DRC 
Data review committee 
eCRF 
Electronic Case Report Forms 
EMR 
Electronic Medical Records 
ESCC 
Esophageal squamous cell carcinoma 
ESCN 
Esophageal squamous cell neoplasia 
ESD 
Endoscopic Submucosal Dissection 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
HFR-HRME 
High Frame Resolution-HRME 
HRME 
High resolution microendoscope 
ICESP 
Instituto do Câncer de Estado de Saõ Paulo 
ICH 
International Conference on Harmonisation  
ICU 
Intensive Care Unit 
ID 
Identification 
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
LCE 
Lugol’s chromoendoscopy 
LED 
Light-Emitting Diode 
LSMEANS 
Least-squares Means 
mHRME 
Mobile HRME 
MOP 
Manual of Procedures 
NBI 
Narrow band imaging 
NCI 
National Cancer Institute 
NCT 
National Clinical Trial 
NIH  
National Institutes of Health 
NPV 
Negative predictive value 
NSR 
Non-Significant Risk 
OHRP 
Office for Human Research Protections 

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PI 
Principal Investigator 
PPV 
Positive predictive value 
PT 
Prothrombin Time 
PTT 
Prothrombin Time Test 
QA 
Quality Assurance 
QC 
Quality Control 
RC 
Research coordinator 
REC 
Research Ethics Committee, Conep  
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SN 
Sensitivity 
SOA 
Schedule of Activities 
SOC 
Standard of care 
SOP 
Standard Operating Procedures 
SP 
Specificity 
SR 
Significant Risk 
UP 
Unanticipated Problem 
US 
United States 
 
 
 

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10.4 PROTOCOL AMENDMENT HISTORY 
Version 
Date 
Description of Change  
Brief Rationale 
2.0 
6 November 
2025 
Changed the Baylor College of 
Medicine Principal Investigator and 
the IND Sponsor-Investigator from 
Sharmila Anandasabapathy to Mimi 
Tan 
There is a change of the Baylor 
College of Medicine Principal 
Investigator and the IND 
Sponsor-Investigator for the 
study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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