A Single-Institutional, Phase 1 Trial of Repeated Oxygen Measurements in Subcutaneous Tumors by Electron Paramagnetic Resonance (EPR) Oximetry Using an Implantable Oxygen Sensor (OxyChip)
Phase: NA
Conditions: Neoplasms, Benign, Neoplasms, Malignant
Sponsor: Periannan Kuppusamy

 
 
Official Title: 
A Single-Institutional, Phase 1 Trial of Repeated Oxygen 
Measurements in Subcutaneous Tumors by EPR Oximetry 
using an Implantable Oxygen Sensor (OxyChip)  
 
NCT number: 
NCT02706197 
Document Type:  
Study Protocol 
Date of the 
Document: 
July 10, 2018 
 
 

 
Version 7.1 July 10, 2018 
 
Clinical Research Protocol 
 
 
 
A Single-Institutional, Phase 1 Trial of Repeated Oxygen Measurements in 
Subcutaneous Tumors by EPR Oximetry using an Implantable Oxygen Sensor 
(OxyChip)  
 
Principal 
Investigators 
 
Clinical 
Philip E Schaner, MD PhD 
Scientific 
Periannan Kuppusamy, PhD 
Co-Investigators 
 
Clinical 
Lesley A Jarvis, MD PhD 
 
Eunice Y Chen, MD PhD 
 
Rebecca A Zuurbier, MD 
 
Roberta M DiFlorio-Alexander, MD 
 
David A Pastel, MD 
 
Jason R Pettus, MD  
                               
 
 
 
 
Scientific 
Benjamin B Williams, PhD 
 
Dan Tse, MD PhD 
 
Eugene Demidenko, PhD  
 
IDE Holder 
IDE Number 
 
 
Periannan Kuppusamy, PhD 
G130260 
Funding Sponsor 
 
Sponsor  
National Cancer Institute 
Address  
BG 9609 MSC 9760, 9609 Medical Center Drive, 
Bethesda, MD 20892-9760 
Award Number 
P01 CA190193 
Award Title 
Direct and Repeated Clinical Measurement of 
pO2 for Enhancing Cancer Therapy 
 
 
Project 2: Tumor oximetry using OxyChip 
Award Period 
07/01/2015 – 06/30/2020 
 
Protocol Numbers 
 
CCRC 
D14007 
CPHS 28499 
Version 
Date 
Modification(s) 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
Version History 
V1 
V2 
 
 
V3 
 
V4 
 
 
 
 
V5 
 
V6 
 
 
 
 
V7 
V7.1 
6/16/2015 
10/23/2015 
 
 
3/7/2016 
 
1/19/2017 
 
 
 
 
3/29/2017 
 
8/28/2017 
 
 
 
 
5/7/ 2018 
7/10/2018 
Initial submission 
Update information regarding tumor stage for 
inclusion criteria, remove platelet count and ANC 
from inclusion criteria, Co-I changes 
Clarification of study procedures, update to 
specify that tumors can be benign 
PI change, expansion of Phase 1A and 1B cohorts 
(justification, results for 6 Patient 1A patients), 
Increase 
implant 
duration 
to 
52 
weeks 
(justification), increase tumor location to 3 cm to 
skin surface 
Add 
ultrasound 
to 
OxyChip 
implantation 
procedure  
Clarification of study procedures, clarification of 
eligibility (no concurrent enrollment in other 
clinical research studies, add platelet count and 
ANC to exclusion criteria), details added about  
OxyChip storage 
Add ultrasound to EPR measurements 
Co-I changes 
                                           V8           10/10/19  
     Co-I changes, evaluation points in Phase 1B 
updated, adding information on adding 
fiducials to OxyChips and OxyChip removal, 
inclusion criteria revised to include minimum 
tumor size  
 
 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
Table of Contents 
 
STUDY SUMMARY 
                                                                                                                     1 
1 
INTRODUCTION 
                                                                                                                     3 
1.1 Background 
3 
1.2 Investigational Device: Category A Device: OxyChip as an oxygen sensor 
3 
1.3 Preclinical Data 
4 
1.3.1 Tumor oxygenation is a critical factor in malignant cancer progression and therapy 
4 
1.3.2 Heterogeneity of oxygen distribution in tumors 
5 
1.3.3 Critical role of oxygen and issues in radiation therapy 
5 
1.3.4 Hyperoxygenation as radiation sensitizer - mixed results 
6 
1.3.5 Methods for oximetry 
6 
1.3.6 EPR oximetry 
7 
1.3.7 Paramagnetic probes for use in clinical EPR oximetry 
7 
1.3.8 Polymer-embedded high-sensitive crystalline probes for use in humans 
8 
1.3.9 Clinical potential of EPR oximetry for direct and repeated measurement of tissue pO2 in 
humans 
8 
1.3.10 General use of in vivo EPR oximetry in pre-clinical models 
8 
1.3.11 Advantages of LiNc-BuO oxygen-sensing crystals for in vivo oximetry 
9 
1.3.12 Embedding of LiNc-BuO crystals in a biocompatible polymer, polydimethylsiloxane    
(PDMS) for safe implantation and retrieval 
10 
1.3.13 In vitro studies established OxyChip as non-toxic to cells 
10 
1.3.14 Long-term oxygen-sensing response of OxyChip 
11 
1.3.15 Lack of toxicity in pre-clinical models with the OxyChip 
11 
1.3.16 Biocompatibility and biosafety evaluation of OxyChip using ISO 10993-12 guidelines 
12 
1.3.17 EPR oximetry in animal models of cancer 
13 
1.4 EPR oximetry in human subjects using ink 
13 
1.5 EPR oximetry using OxyChip in cancer patients (Progress to-date) 
14 
1.5.1 Enrollment, implantation, and explantation of OxyChip 
14 
1.5.2 pO2 measurements 
15 
1.5.3 Pathologic evaluation 
Error! Bookmark not defined. 
1.5.4 Integrity and calibration of OxyChip 
18 
1.5.5 Compliance with FDA and Dartmouth IRB regulation 
18 
1.5.6 Summary 
19 
1.6 Justification of cohort design and revisions of the protocol 
20 
1.6.1 Rationale for expanding Phase 1A and Phase 1B Cohorts 
20 
1.6.2 Rationale for increasing the duration of residency of the OxyChip in a tumor 
21 
1.6.3 Rationale for the option of implanting fiducials with the OxyChip 
21 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
1.7 Risk/Benefits 
22 
2 
STUDY OBJECTIVES 
                                                                                                       23 
2.1 Primary Objective 
23 
2.2 Secondary Objective 
23 
2.3 Exploratory Objective 
23 
3 
STUDY DESIGN 
                                                                                                                   24 
3.1 General Design 
24 
3.2 Primary Study Endpoint 
27 
3.3 Secondary Study Endpoint 
28 
4 
SUBJECT SELECTION AND WITHDRAWAL 
                                                                   28 
4.1 Inclusion Criteria 
28 
4.2 Exclusion Criteria 
28 
4.3 Subject Recruitment and Screening 
29 
4.4 Early Withdrawal of Subjects 
29 
4.4.1 When and how to withdraw subjects 
29 
4.4.2 Data collection and follow-up for withdrawn subjects 
29 
5 
STUDY DEVICE 
                                                                                                                   29 
5.1 Description 
29 
5.1.1 Materials used for fabrication 
30 
5.1.2 Synthesis of LiNc-BuO crystals 
30 
5.1.3 Method for fabrication of OxyChip 
30 
5.1.4 Sterilization 
30 
5.1.5 Calibration of oxygen sensitivity 
30 
5.2 Treatment Regimen 
31 
5.2.1 OxyChip and fiducial placement 
31 
5.2.2 Oxygen measurements 
32 
5.2.3 Safety of EPR measurements 
32 
5.2.4 OxyChip removal 
33 
5.2.5 Tissue processing 
34 
5.3 Subject Compliance Monitoring 
34 
5.4 Prior and Concomitant Therapy 
35 
5.5 Packaging 
35 
5.6 Receiving, Storage, Dispensing and Return 
35 
5.6.1 Receipt of study device 
35 
5.6.2 Storage 
35 
5.6.3 Dispensing of study device 
35 
5.6.4 Return or destruction of study device 
35 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
6 
STUDY PROCEDURES 
                                                                                                       36 
6.1 Pre-enrollment (Phase 1A, 1B) 
36 
6.2 Placement of the OxyChip (Phase 1A, 1B) 
36 
6.3 Post OxyChip implantation aseessment (Phase 1A, 1B) 
36 
6.4 Oxygen measurements (Phase 1A, 1B) 
36 
6.5 Pre-operative assessment (Phase 1A, 1B) 
36 
6.6 Removal of OxyChip (Phase 1A, 1B) 
37 
6.7 Visits after removal of the OxyChip (Phase 1A, 1B) 
37 
7 
STATISTICAL PLAN 
                                                                                                       37 
7.1 Statistical Methods 
37 
7.2 Subject Population(s) for Analysis 
37 
8 
SAFETY AND ADVERSE EVENTS                                                                                            38 
8.1 Definitions 
38 
8.1.1 Adverse event definitions 
38 
8.1.2 Unanticipated adverse device effect (UADE) 
38 
8.2 Recording of Adverse Events 
38 
8.3 Reporting of Adverse Device Effects and Unanticipated Problems 
38 
8.3.1 Investigator reporting: Notifying the study sponsor 
38 
8.3.2 Reporting of adverse effects to the responsible IRB 
40 
8.4 Stopping Rules 
40 
8.5 Medical Monitoring 
40 
9 
DATA HANDLING AND RECORD KEEPING 
                                                                   41 
9.1 Confidentiality 
41 
9.2 Source Documents 
41 
9.3 Case Report Forms 
41 
9.4 Records Retention 
41 
10 STUDY MONITORING, AUDITING, AND INSPECTING 
                                                       41 
10.1 Study Monitoring Plan 
41 
10.2 On-Site Monitoring 
42 
10.3 Auditing and Inspecting 
42 
11 ETHICAL CONSIDERATIONS                                                                                                    42 
11.1 Funding Source 
42 
11.2 Conflict of Interest 
42 
12 PUBLICATION PLAN 
                                                                                                       42 
13 REFERENCES                                                                                                                          43 
14 ATTACHMENTS (AS SUBMITTED TO THE FDA IN AUG 6, 2014)                                            56 
 

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List of Abbreviations 
 
BOLD MRI - blood oxygen level-dependent MRI 
CCRC 
- Clinical Cancer Review Committee 
CO2 
- 
carbon dioxide 
CPHS  
- Committee for the Protection of Human Subjects (Dartmouth’s IRB used by DHMC) 
CRF  
- case report form 
CT 
- computerized tomography 
DHMC  
- Dartmouth-Hitchcock Medical Center 
DSMAC  
- Data Safety Monitoring and Accrual Committee  
DWI 
- diffusion-weighted imaging 
EPR 
-  electron paramagnetic resonance 
FDA 
- Food and Drug Administration (US Dept of Health and Human Services) 
FTIR 
- Fourier transform infrared spectroscopy 
GC-MS 
- Gas chromatography - mass spectrometry 
GHz 
- gigahertz 
Gy 
- gray 
HIF-1alpha - hypoxia-inducible factor-1 alpha  
HIPAA 
- Health Insurance Portability and Accountability Act of 1996  
ICP-MS 
- Inductively coupled plasma – mass spectrometry 
LiNc 
- lithium naphthalocyanine 
LiNc-BuO 
- lithium octa-n-butoxynaphthalocyanine 
LiPc 
- lithium phthalocyanine 
MRI  
- magnetic resonance imaging 
MHz 
- megahertz 
NCCC  
- Norris Cotton Cancer Center 
NIR 
- near-infrared  
NMR 
- nuclear magnetic resonance 
O2 
- 
molecular oxygen 
OxyChip  
- oxygen-sensing probe made by embedding LiNc-BuO in PDMS 
PDMS  
- polydimethylsiloxane 
PHI  
- patient health information 
pO2  
- partial pressure of oxygen 
UADE 
- unanticipated adverse device effect 
 

EPR Oximetry using OxyChip 
 
 
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Version 7.1 July 10, 2018 
 
Study Summary 
Title 
A Single-Institutional, Phase I Trial of Repeated Oxygen Measurements in 
Subcutaneous Tumors by Electron Paramagnetic Resonance (EPR) Oximetry 
using an Implantable Oxygen Sensor (OxyChip) 
Short Title 
EPR Oximetry using OxyChip 
Protocol Number 
D14007, CPHS 28499 
Phase 
First-in-humans, early feasibility study for OxyChip implantation with 
subsequent expansion to a larger Phase I trial. Phases: 1A (tumor with 
planned surgical resection only and consequently with an expected duration 
of implantation for up to 4 weeks); and 1B (tumor with neoadjuvant radiation 
therapy or chemotherapy followed by planned surgical resection, with 
expected duration of implantation of up to 12 weeks for radiation and 24 
weeks or more for chemotherapy.)  OxyChip implant duration for both phases 
can be extended to 52 weeks excluding the first 6 patients enrolled into 
Phase 1A where implant duration is up to 4 weeks. 
Methodology 
Phase I (first-in-human, early feasibility trial) 
Study Duration 
5 years 
Study Center(s) 
Single institution: Dartmouth-Hitchcock Medical Center (DHMC) 
Objectives 
Primary: Establishment of safety of OxyChip implantation in humans; 
Secondary: establishment of feasibility of OxyChip for measurements of 
oxygen using EPR oximetry in humans.  
Number of Subjects 
60 total evaluable subjects planned: 3 subjects in Phase1A  will be evaluated 
and reviewed before enrolling another 3 subjects. After completion of the first 
6 subjects in Phase 1A, if there are no unacceptable toxicities from the 
OxyChip, that cohort will be expanded to a total of 30 subjects. Phase 1B will 
consist of one cohort of 3 subjects receiving chemotherapy and one cohort of 
3 subjects receiving radiotherapy. Once a cohort has enrolled 3 subjects and 
there are no unacceptable toxicities from the OxyChip, the completed cohort 
will be expanded to enroll additional subjects. No more than 30 subjects will 
be enrolled in Phase 1B. Phase 1A and Phase 1B will be evaluated 
separately with regards to this expansion; i.e., Phase 1A may expand to 30 
subjects while Phase 1B is still accruing.  
Diagnosis and Main 
Inclusion Criteria 
Tumors, located within 3 cm of skin or mucosal surface AND tumor resection 
is planned. 
Study Product, Dose, 
Route, Regimen 
OxyChip containing lithium octa-n-butoxynaphthalocyanine (LiNc-BuO) 
oxygen-sensing crystals embedded in polydimethylsiloxane (PDMS) polymer 
to be used in recording oxygen levels in tumors using EPR oximetry. 
Duration of 
Administration 
Implantation time up to 4 weeks for the first six Phase 1A patients, but ≤52 
weeks for the additional 24 patients. The duration of the course of radiation 
therapy or neoadjuvant chemotherapy for phase 1B patients, but ≤52 weeks. 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
Reference therapy 
N/A 
Statistical 
Methodology 
This is a pilot study designed to (1) test the safety of the OxyChip, (2) test the 
feasibility of taking EPR measurements repeatedly with the OxyChip, and (3) 
help design larger studies to evaluate oxygen adaptive therapies. We will 
proceed by initially enrolling 3 patients in a cohort and evaluate the initial (and 
each subsequent) cohort of 3 patients for adverse events prior to proceeding 
to the next cohort. As a secondary goal, we will investigate the feasibility of 
repeated oxygen measurements using EPR oximetry.  
 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
1 Introduction 
This document is a protocol for a human research study. This study is to be conducted according to US 
and international standards of Good Clinical Practice (International Conference on Harmonization ICHE6), 
the Code of Federal Regulations Title 21 parts 803 and 812, and other applicable government regulations 
and Institutional (Dartmouth’s Committee for the Protection of Human Subjects, CPHS) research policies 
and procedures.  
1.1 Background 
Tumor hypoxia (low oxygen levels) confers a poor prognosis and resistance to standard radiotherapy in the 
treatment of many tumor types. Based on oxygen measurements using polarographic electrode and 
hypoxia markers, several research groups1,2 have shown that tumor hypoxia is a poor prognostic factor; 
hypoxic tumors are more resistant to radiotherapy and chemotherapy and have increased malignant 
potential. Oxygen measurements using a polarographic electrode have been performed pre-treatment but 
are difficult to perform repeatedly during or after treatment to assess tumor or tissue oxygenation. Hypoxia 
markers (exogenous substances such as misonidazole and pimonidazole, or endogenous markers such as 
hypoxia-inducible factor-1 alpha (HIF-1 alpha) and carbonic anhydrase IX (CA IX)) are used to visualize 
hypoxic areas in histological specimens. The histologic methods only provide a static picture of oxygenation 
which, in vivo, is likely to be in constant flux3-5. Knowing the fluctuations in tissue oxygenation may be critical 
for determining the optimal treatment and the risk of post-treatment complications, thereby optimizing the 
therapeutic ratio. Such an assessment requires the means to make repeated direct measurements of 
oxygen in tissue at specific sites, a capability that is not available at present. Thus, there is an unmet need 
for a device capable of monitoring tumor tissue oxygenation. Achieving this capability would have very 
significant implications in cancer treatment. 
Electron paramagnetic resonance (EPR) oximetry has the potential to fulfill this clinical need. EPR oximetry 
has been established in both animal models and initial clinical studies at Dartmouth to be a very effective 
method for measuring oxygen in tissues or tumors directly, repeatedly, and non-invasively following an 
initial introduction of the paramagnetic EPR reporter material6. However, the existing approach for the 
clinical use of EPR is limited due to the unavailability of a sensitive and reliable oxygen-sensing probe. New 
oxygen-sensing probes have shown superior characteristics in pre-clinical models, opening up the clinical 
use of this technology more broadly and importantly to tumors in need of hypoxic monitoring and 
intervention. We are developing a translational program to apply EPR oximetry more broadly in clinical 
practice to improve radiation therapy. The first step in this development work is to bring the paramagnetic 
oxygen-sensing crystals, lithium octa-n-butoxynaphthalocyanine (LiNc-BuO), into clinical use.  
1.2 Investigational Device: Category A Device: OxyChip as an oxygen sensor 
The Category A investigational device that we are proposing to use is a small cylindrical piece (0.6 mm 
diameter x 3-5 mm length) of implantable material, called OxyChip. A summary of the components of the 
OxyChip is as follows: 
 
Materials in OxyChip 
Prior Clinical Use 
1. Lithium octa-n-butoxy- 
naphthalocyanine (LiNc-
BuO) (oxygen-sensing 
crystal) 
This trial represents the first clinical use of LiNc-BuO in 
humans. The LiNc-BuO will be embedded in a 
biocompatible polymer, polydimethylsiloxane (PDMS), 
which is approved by the FDA for clinical use. 
2. PDMS polymer 
(embedding material) 
Biocompatible and in clinical use* 
 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
*PDMS has been in use in blood pumps, cardiac pacemaker leads, mammary prostheses, drainage 
implants in glaucoma, artificial skin, maxillofacial reconstruction, replacement esophagus, contact lenses, 
oxygenators, medical adhesives, finger joints, coating for cochlear implants, catheters, drug-delivery 
systems and denture liners. 
OxyChip is a Category A device (see definition below), as it is an innovative device being tested for the first 
time in human subjects and the absolute risk of the device has not been established. This study will 
establish the safety and efficacy of the device for use in humans. The device is Class III (see definition 
below) only because it is implanted. It is not a life-supporting or life-sustaining device. 
Category A Device 
A Category A device refers to an innovative device believed to be in Class III for which the "absolute risk" 
of the device type has not been established (that is, initial questions of safety and efficacy have not been 
resolved, and the FDA is unsure whether the device type can be safe and effective). 
Note: Category A devices are NOT eligible for Medicare coverage. 
Class III Device 
A Class III device has/requires the following: 
Risk: High; devices that present serious risk; most typically these are implanted and are life-supporting or 
life-sustaining devices. 
Special FDA controls through pre-market review: The pre-market review involves a comprehensive 
evaluation, including data from clinical studies, and is required to ensure safety and efficacy prior to 
marketing of the devices. This involves bench and animal tests, clinical trials, and the submission of a 
Premarket Approval (PMA) application. 
1.3 Preclinical Data 
Extensive preclinical data obtained using animal models and clinical studies in humans have established 
the efficacy and safety of EPR oximetry. The use of the OxyChip as a probe for EPR oximetry has been 
studied extensively in animals, which justifies the translation of this technique to clinical trials in humans. 
This section (1.3) focuses on the pre-clinical data for oximetry using the OxyChip as a probe. In addition, 
the clinical data for EPR oximetry in tissues with probe other than the OxyChip are reviewed below in 
Section 1.4.  
1.3.1 Tumor oxygenation is a critical factor in malignant cancer progression and 
therapy 
Based on data from the use of the Eppendorf technique and other studies, it has been concluded that the 
partial pressure of oxygen (pO2) in solid tumors is the most important parameter affecting clinical outcomes. 
Pretreatment pO2 level in solid malignancies, measured by oxygen electrodes, has been shown to be the 
most important determinant of the therapeutic response, especially to radiation therapy7-12. This 
dependency on oxygen levels appears to be more significant than stage, tumor morphology, or tumor size. 
There are also data that indicate oxygen levels are very important factors in the response to surgical and 
chemotherapeutic approaches13,14 in addition to radiation therapy. For example, in squamous cell 
carcinomas (SCC) of both the head and neck1,15-17 and cervix18,19. The oxygen level in tumors not only 
affects the response of tumors to therapy but also the malignant progression of tumors. This dependency 
of outcomes on oxygen levels may be related to the well-established observation that the level of oxygen 
can significantly affect the nature of the tumor, with hypoxia leading to more aggressive behavior of tumors 
through mechanisms that are being increasingly understood12,20,21. 
In addition to influencing treatment efficacy, oxygen levels of the tissues in the tumor bed can influence 
outcomes related to the morbidity of therapy. Information about pO2 at critical sites will be useful for 
enhancing treatment options to facilitate wound healing, and the utility of reconstructive tissue 
transplantation, especially when surgery and radiation are used in combination. 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
Oxygen levels in tumors change with time. These changes include those occurring across very short time 
scales related to underlying pathophysiology, those induced by tumor growth, and those induced by 
treatment itself. Therefore, it is very desirable to monitor the oxygen level in tumors before, during, and after 
therapeutic interventions. This requires a means to make direct and repeated measurements of oxygen in 
tissue at specific sites, a capability that is not available in the clinic. Achieving this capability would have 
very significant implications for improving cancer therapy across a patient’s clinical course, from initial 
diagnosis to primary treatment to post-treatment morbidity.  
1.3.2 Heterogeneity of oxygen distribution in tumors 
The basis for the above conclusions about what is needed clinically to be useful, at first consideration, 
appears to ignore the well-known heterogeneity of oxygen in tumors. There are two principal aspects in our 
consideration of this important topic. First, heterogeneity of oxygen in tumors has been fairly well 
characterized22-24 and second, there is now general acceptance that the amount and sites of hypoxia 
change both with time and spatially over distances as small as the cell5,25-33. Temporal changes in flow and 
in the number of red cells in capillaries have been shown to vary over seconds34,35. Point measurements of 
oxygen and distributions of markers of blood flow have indicated that, at the level of the circulatory unit and 
larger aggregates of cells, the local pO2 can vary significantly within time constants of minutes to days28,29. 
It also has been argued that chronic hypoxia, which does not vary with time, is not especially clinically 
relevant because of the known effects of prolonged hypoxia on tumor cell viability. There is also good 
evidence that there are significant gradients in oxygen over cellular dimensions and that, within an individual 
cell, there can be significant oxygen gradients that include the nucleus. The practical implication of this 
evidence is that it probably will not be possible, by any technique, to achieve sufficient resolution of 
heterogeneity to carry out therapy based on the specific location of the hypoxic regions. This is because 
these hypoxic regions will be changing within timeframes too short to be used to deliver radiation selectively 
to the hypoxic areas. It will, however, be useful to determine if the tumor has hypoxic areas and especially 
whether procedures designed to increase oxygenation are effective and the time period over which they 
are effective. This requires repeated measurements; however, it does not require (or indeed does not 
benefit from) spatial resolution of the heterogeneity. 
Experimental results from our lab and other labs indicate that the ability to monitor the tumor pO2 repeatedly 
and directly does provide information on the extent and time dependency of overall oxygenation in the 
tumor, information that is needed for utilization in clinical decision making36,37. These empirical results 
support the conceptual premise that, while the pO2 within the tumor will vary, factors that affect oxygenation 
will affect most or all parts of the tumor, and therefore monitoring at several sites will provide the information 
that is needed for clinical decision-making. While we believe that it is reasonable to expect that this result, 
as obtained in animal models, will translate to the clinical setting, we also recognize that one of the key 
aspects of our proposed research is to test this hypothesis in human subjects, as well as to demonstrate 
that this information can then  be used to affect treatment outcomes. 
In summary, considering the fact that local hypoxia is too dynamic to pinpoint spatially in a clinically useful 
manner, although certainly an important factor in the response to therapy and clinical progression, the key 
to clinical success will likely be finding a method to follow changes in overall oxygenation and to ascertain 
responsiveness to interventions to modify oxygenation. We believe that there is an excellent opportunity for 
our approach using EPR oximetry to provide the information needed to do this. At the present time there is 
no other method available clinically to make repeated direct measurements of tumor pO2, with or without 
the ability to resolve regional hypoxic areas, and in vivo EPR oximetry has a very plausible capability to 
make these measurements in several sites simultaneously and repeatedly over time. 
1.3.3 Critical role of oxygen and issues in radiation therapy 
Recent developments in radiation oncology have further increased the need to measure tumor pO2 
accurately and repeatedly. Changes in the radiation fraction per dose, especially hypofractionation with 
single doses of up to 20 or more gray, have led to unexpected clinical effectiveness, raising the need to 
understand the basis of these effects. Changes in oxygenation are among the most likely factors that are 
involved. The results from another new clinical approach, modification of angiogenesis, have also been 
surprising and puzzling. Implementation of clinical protocols based on the excellent preclinical studies that 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
indicated a window of opportunity with the “normalization” of the tumor vasculature has been 
disappointing38,39. An adequate understanding of the clinical results would be greatly advanced by the ability 
to repeatedly monitor the oxygen levels in tumors.  
1.3.4 Hyperoxygenation as radiation sensitizer - mixed results 
Perhaps the most effective and most readily implementable modification of radiation therapy would be to 
monitor tumor pO2 to facilitate hyperoxygenation regimes in order to enhance the response of tumors to 
radiation. Because of the well-known effect of oxygen on radiation response, there have been many 
attempts to sensitize tumors by increasing their oxygen levels at the time of treatment. Although some 
positive effects have been found, in general, the results have been disappointing. Our initial clinical 
measurements with EPR oximetry suggested an explanation for some of the disappointing results of 
hyperoxic therapy. Using a very simple and readily implementable test regime we have found profound 
differences in the response of tumors to a simple and readily implementable hyperoxygenation treatment, 
which is breathing oxygen-enriched gases. In our preliminary studies in a limited number of patients with 
various superficial malignancies, we found marked differences in the response of tumors when the subject 
breathed oxygen-enriched gas mixtures. Some tumors showed large responses in tumor pO2, while others 
had little or no changes. It is likely that this is a general phenomenon, whose basis is readily understood 
because of the complex and fragile nature of the blood supply to tumors. This leads to a simple, testable 
hypothesis that could be definitively tested by EPR oximetry within the usual clinical setting. We hypothesize 
that by monitoring the changes in tumor oxygen while breathing gas mixtures containing higher oxygen 
content (e.g., 100% oxygen or carbogen, a mixture of 95% O2 and 5% CO2), we can assess the timeframe 
of hyperoxygenation and thereby administer radiation therapy at times when tumors will respond maximally. 
We could accomplish the determination of likely responders and of the window for treatment (which may 
vary among patients) by using EPR oximetry to make repeated non-invasive measurements of tumor pO2. 
The benefit of EPR oximetry will thus apply in both a general manner, by establishing improved standard 
protocols (e.g., improved guidance regarding time between fractionated doses of radiation therapy, 
optimized timing of combined therapy involving radiation and chemotherapy and/or surgery), and on a 
patient-specific basis to enhance individualized therapy (e.g., following the oxygen levels and altering the 
timing of fractions to maximize therapeutic effect for a specific patient). For the individual patient this would 
enable us to deliver therapies at times when the tumors have more optimum oxygen concentrations, which 
in turn could significantly improve the therapeutic ratio of the treatments, and which should lead to improved 
outcomes. 
1.3.5 Methods for oximetry 
While a few techniques are available that can provide direct measurements of tumor pO2 (especially oxygen 
polarographic electrodes, the OxyLite fluorescence-quenching technique and direct injection of oxygen-
sensitive NMR probes based on fluorine40-43), these techniques have the disadvantage of not being able to 
be used repeatedly. This is a significant limitation because the most valuable clinical usefulness depends 
on obtaining repeated measurements. There are also some concerns about the potential for significant 
disadvantages if the invasiveness of these techniques causes some artifacts precisely at the time that the 
measurements are being made44-48. To date, only the polarographic method has been systematically used 
in humans. Some widely available non-invasive techniques to assess oxygenation provide data on 
parameters that, while related to tissue pO2, do not measure pO2 directly. This especially includes 
techniques such as blood oxygen level-dependent magnetic resonance imaging (BOLD MRI), nuclear 
magnetic resonance (NMR) proton spectroscopy, diffusion-weighted imaging (DWI) MRI, duplex Doppler 
ultrasound,18 F-Miso PET, and near-infrared (NIR) measurements of hemoglobin. These techniques can 
provide information on the saturation of hemoglobin within the vascular system or redox-related metabolites 
or reactions, but, while this can be valuable to know, it does not provide direct quantification of the pO2 in 
the tumor and surrounding tissues. The clinical importance of direct measurement of pO2 is especially high 
in tumors, where typically the microvasculature is complex and irregular, making it very difficult to 
extrapolate these indirect measurements to the pO2 in the tumor49-51. EPR oximetry could provide the data 
to facilitate relating these indirect methods to the actual tumor or tissue pO2, and thereby clarifying the 
conditions under which these other methods can provide the desired clinically relevant information on tumor 
pO2. 

EPR Oximetry using OxyChip 
 
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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
1.3.6 EPR oximetry 
EPR oximetry refers to the measurement of oxygen concentration by EPR spectroscopy52. The basis of 
EPR oximetry is the physical interaction between molecular oxygen (O2) and paramagnetic material probes 
that are introduced into the tissue of interest. As O2 has two unpaired spins in the ground state, it can have 
an especially strong effect on the EPR spectra of the introduced probes. Discussion of interactions between 
the specific probes and O2 are given in several manuscripts devoted to characterization of chars53,54 and 
LiPc and derivatives55,56. Briefly, if O2 approaches the probe within such proximity that there is appreciable 
overlap of the quantum mechanical wave functions of their unpaired electrons, then a spin-exchange 
interaction will occur. Under certain conditions which are met with the oxygen-sensitive materials, this 
exchange results in broadening of the spectral features through shortening of the relaxation times of the 
introduced paramagnetic material or reduction of existing exchange-narrowing, depending on the probe. 
When this broadening is calibrated against a range of gases of known pO2, the resulting calibration curve 
can be used to provide data on the oxygenation of the tissue surrounding the material. The fact that the 
widths of EPR resonance lines correlate with oxygen concentration has been used in a variety of biological 
settings57-70. 
The development of low-frequency EPR instrumentation at L-band (1-2 GHz) and even lower frequencies 
(600 MHz or 300 MHz) has made it possible to perform EPR oximetry measurements in animals and 
isolated functioning organs58,71,72. Unfortunately, clinical EPR must confront the fact that the depth of 
penetration will continue to be a limiting factor, unless further advances in hardware design and their 
applications are successful. Generally speaking, noninvasive EPR measurements are limited to a 
penetration depth at the range of 1–2 cm at L-band (~1.2 GHz). Penetration depth can be increased to 8 
cm or more by lowering the frequency to the 300-600 MHz range. The tradeoff, however, is that the signal-
to-noise ratio significantly decreases at these lower frequencies, causing a decrease in spatial resolution 
and accuracy of pO2 measurements. 
1.3.7 Paramagnetic probes for use in clinical EPR oximetry 
Measurement of oxygen-induced EPR line-broadening requires the presence of a suitable paramagnetic 
probe in the tissue region of interest. Two types of probes are used: (i) soluble probes that report the 
concentration of dissolved oxygen and (ii) particulate probes that measure partial pressure of oxygen (pO2) 
in the milieu. Considerable progress has been made in the development and use of both types of probes. 
The soluble probes provide the potential for imaging but have potential limitations in their sensitivity and 
ability to repeat the measurements. Nevertheless, they have been very successful in a number of 
applications in preclinical models.  
There are certain advantages in using particulate probes including: (i) high resolution in the range of 0.1 
torr (mmHg); (ii) suitability for repeated measurements in vivo without reintroduction of the probe into the 
tissue; (iii) non-invasive measurement – after a one-time introduction of the probe, subsequent 
measurements are performed under noninvasive conditions; (iv) accuracy - highly reproducible 
measurements correlate closely with those made by other methods; (v) localized measurements are made 
from a single voxel/region containing the particulate – thus the spatial resolution is the size of the particulate 
deposit; (vi) insolubility in aqueous solvents; (vii) no effect of the various biological oxidoreductants, pH, 
temperature etc.; (viii) nontoxic - the probes are inert in biological systems; (ix) temporal response is very 
good, usually less than a second; and finally, (x) probes respond to partial pressure of oxygen (pO2), rather 
than concentration of oxygen, as the latter may be quite heterogeneous in cellular/tissue environments due 
to the solubility of oxygen and hence calibration can be difficult. The use of both the naturally occurring 
(coals, fusinite)54,73-80, semisynthetic (India ink, sugar chars, carbon blacks)81-86 and purely synthetic 
materials (e.g., lithium phthalocyanine and derivatives)55,56,63,64,68,87-99 have been reported for EPR oximetry. 
The particulate probes typically are introduced into tissues using a needle syringe, often several days prior 
to measurement in order to minimize trauma and allow for healing and incorporation of the material into the 
tissue prior to pO2 measurement. An advantage of the particulate approach is that once the probe has been 
introduced, we can make repeated measurements at the same location without the need to introduce 
additional material or wait for introduced material to be cleared. This characteristic is particularly useful for 
the monitoring of tissue oxygenation during the development of disease or in response to therapy, as is 
needed for the optimal treatment of solid tumor cancers and peripheral vascular disease. 

EPR Oximetry using OxyChip 
 
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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
India ink was the first probe used for oxygen measurements in humans81,82. India ink has a long history of 
clinical use as an anatomic marker for surgery and radiotherapy and, fortuitously, the suspended carbon 
black particles contain stable radical species at sufficient concentrations with EPR spectra that are highly 
sensitive to the presence of oxygen82,85. Charcoal, a naturally occurring carbonaceous material, has been 
extensively characterized for EPR oximetry in animal models73,78,100. Charcoal has been approved for 
clinical use (as a tissue marker) in Europe. Despite their availability for clinical use, the carbon-based 
oxygen sensors have some limitations including limited sensitivity to oxygen and, if used as suspensions, 
the potential to diffuse. Alternatively, purely synthetic materials, such as lithium phthalocyanine68 or 
naphthalocyanine101 and derivatives56,99, are ideally suited for clinical EPR oximetry. 
1.3.8 Polymer-embedded high-sensitive crystalline probes for use in humans 
The most notable drawback and potential limitation to the use of the crystalline materials for clinical 
applications is the need to leave them permanently in the tissue, which may present practical barriers for 
obtaining approval for use in human subjects. To address this concern, we have developed an alternative 
approach for their clinical use. The raw particulates (usually 10-100 micron size) are embedded in 
biocompatible materials that have high oxygen permeability73,77,102-105. The probes are effectively shielded 
from interaction with the biological milieu that could result in biochemical degradation and breakdown, as 
well as limit the probability of local and/or systemic toxicity effects from interactions of the probe with the 
tissues. The implants could be left in the tissue or removed when no longer needed. We have used 
polydimethylsiloxane (PDMS), a silicone polymer with properties desirable for holding of oximetry probes. 
PDMS is biocompatible, highly flexible, oxygen permeable, and has been used in a wide range of medical 
device and health-care applications. Furthermore, PDMS has been approved for use in human subjects 
and is one of the reference materials provided by the National Heart Lung and Blood Institute for 
standardized biocompatibility testing. We have used PDMS to embed/hold LiNc-BuO crystals and 
developed the implants (OxyChip) in the form of easily implantable shapes and sizes. The efficacy and 
safety of the OxyChip has been well characterized in animal models102-105.  
1.3.9 Clinical potential of EPR oximetry for direct and repeated measurement of tissue 
pO2 in humans 
Although several other existing methods are utilized to measure oxygen concentrations in vivo in human 
subjects, a suitable technique for noninvasive and repeated direct measurements of oxygen in the same 
tissue or cells on a temporal scale is not available currently. EPR oximetry enables reliable and accurate 
measurements of the pO252. EPR oximetry can measure pO2 directly in the tissue and can be performed at 
the actual site(s) of interest. The placement of the paramagnetic material directly at the site of interest, 
where it remains and can be interrogated after any temporary perturbation has resolved, also avoids 
potential concerns about damaging the tissue at the time of measurement112. The ability of EPR oximetry 
to make repeated measurements from localized sites provides a very important capability that can support 
critical aspects of a number of biomedical applications. The value of EPR oximetry based on stable oxygen-
sensitive paramagnetic materials has been shown in animal models to be a very effective method to 
measure oxygen in tissues directly, repeatedly, and non-invasively. Ongoing clinical studies at Dartmouth 
have confirmed that the method can be extended to human subjects very effectively, meeting a currently 
important but unmet need - the ability to make repeated, direct measurements of oxygen (pO2) in tissue at 
specific sites6,85,86,112-114. These studies also have provided very useful information as to what further 
developments are needed to achieve the full clinical potential of the technique and its use to enhance 
cancer therapy. This capability would be a new addition to clinical medicine that would immediately and 
significantly enhance treatment of malignancies. 
1.3.10 General use of in vivo EPR oximetry in pre-clinical models 
EPR oximetry, based on particulate probes, has been used to study oxygenation in numerous pre-clinical 
models to obtain oxygen concentration in different anatomic locations, including the brain46,47,62,68,113,115-144, 
heart64-66,89,90,145-154, tumors24,36,50,62,63,88-90,123,129,134,135,139-144,155-180, gastrointestinal tract76,181, muscle 182,183, 
liver82-84,184, kidney185, skin186, and wound healing112,187-190. Of note, there are over 350 peer-reviewed 
publications on EPR oximetry, underscoring the extensive pre-clinical development that has been 
accomplished to prepare this technique for clinical use.  

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EPR Oximetry using OxyChip 
 
Page 12 
 
CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
 (indicated by the ‘F’ in the images), between the inflammatory cells and the underlying muscle tissue, 
represents the fibrous capsule. The average thickness of the capsule was 34.89 ±11.05 µm and indicated 
that the fibrous encapsulation was minimal. It must be noted that the acute inflammatory response and 
subsequent formation of a fibrous capsule did not have any significant effect on the in vivo oxygen-sensing 
ability of the chip103. The calibration remained linear, with no significant difference in oxygen sensitivity, 
compared to a control chip that was not implanted in the animal. Overall, the results demonstrated the 
biocompatibility and biostability of the chip, with almost no effect on the intended functionality of the chip 
due to extended in vivo residence.  
1.3.16 Biocompatibility and biosafety evaluation of OxyChip using ISO 10993-12 
guidelines 
Since PDMS is established as a safe material for use as implants in humans, and the only other material 
that is part of the chip is LiNc-BuO, which is embedded in PDMS, we sought to determine that LiNc-BuO 
Figure 4. Biocompatibility of OxyChip. Images of the tissue sections, stained with 
hematoxylin and eosin, obtained using a light microscope at four different 
magnifications (40x, 100x, 200x, and 400x). The region where the implant was present 
is indicated as ‘C’ in the images, while the normal muscle tissue is depicted as ‘M’. 
The letters ‘P’ and ‘F’ denote the dark nuclei of polymorphonuclear leukocytes 
(PMNs), and the pink band of fibrous tissue encapsulating the implant area, 
respectively. Images demonstrate that the implant triggered an acute inflammatory 
response, with minimal fibrous encapsulation. Average capsule thickness, estimated 
using MetaMorph software, was 34.89 ± 11.05 µm (n = 56 measurements). However, 
any fibrous capsule formation observed did not affect the in vivo oxygen-sensing 
ability of the implanted chip. The results show that OxyChip exhibited good in vivo 
biocompatibility and biostability. 

EPR Oximetry using OxyChip 
 
Page 13 
 
CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
crystals are held within the polymer and that there are no debris or leachables released from the implant 
upon long-term implantation in tissues. We performed chemical characterization analysis on the final 
sterilized OxyChips according to ISO 10993-12 specifications to ensure no other residues are detected and 
that the only material detectable in the device is PDMS. The chemical characterization analysis included 
Gas Chromatography Mass Spectroscopy (GC-MS) to detect the presence of organic leachables, 
Inductively Coupled Plasma Mass Spectrometry (ICP-MS) to detect the presence of heavy metals and 
inorganic leachables, and Fourier Transform Infrared Spectroscopy (FTIR) to identify the presence of the 
PDMS material in the extracts. The extraction conditions were as recommended in ISO 10993-12:2012 
guidelines for a device that is <0.5-mm thick with both polar and non-polar solvents and at 50°C. A brief 
summary and conclusion of the analysis is given below (Please see Attachment 10: Report of ISO 10993-
12: 2012 Chemical characterization analysis for a complete report of the study). 
GC-MS: According to the putative identifications, the solvent extraction did not contain any of the organic 
volatile impurities listed in USP Guidance 467 (United States Pharmacopeia and National Formulary (USP 
37-NF 32). Vol 1. Rockville, MD: United States Pharmacopeia Convention; 2014:215-227) above their 
defined concentration limits.  
ICP-MS: Inductively Coupled Plasma- Mass Spectrometry (ICP-MS) was used to quantify and qualify the 
extractable elemental impurities from the component (OxyChip device). The samples were measured for 
heavy metals and elemental impurities using an external calibration approach against calibration solutions 
prepared in the same diluent as samples. The results showed 399 parts per billion (ppb) of lithium and 53 
parts per billion of copper (Cu) in the device water extract samples. The device was found to contain low 
levels of low risk excipients. 
FT-IR: The identity of polydimethylsiloxane (PDMS) material in the OxyChip was tested and confirmed by 
comparing the Infrared (IR) Spectra of the OxyChip sample with a PDMS control (OxyChip without the 
sensor, i.e. PDMS alone) and a PDMS reference standard (USP Lot J0L500). Based upon the maxima 
exhibited, as compared to the USP reference standard (±10 cm-1 as per USP <851> Spectrophotometry 
and Light-Scattering), the identity of PDMS in sample was confirmed. 
In conclusion, the chemical characterization analysis of sterilized OxyChips did not show any organic 
volatile impurities above USP Guidance or metals of high risk, suggesting that the device is biocompatible 
and thus safe for implantation. 
1.3.17 EPR oximetry in animal models of cancer 
Repeated oxygen measurements with EPR oximetry have been used in a mouse model system of soft 
tissue sarcoma, using radiation-induced fibrosarcoma tumor (RIF-1) cells. Most importantly, it was found 
that when oxygen levels were used to guide delivery of radiation, there was a delay in tumor growth139,169, 
and oxygen levels were found to increase in RIF-1 tumors with carbogen breathing63. Similar oxygen 
measurements and oxygen response were measured in RIF-1 tumors using either the OxyChip102,174 or in 
TLT tumors using charcoal powder161,174 and as well in experiments using orthotropic 9L and C6 gliomas 
implanted in the brain of rat138. These studies suggest that there is a potential for improved tumor control 
by delivering radiation when tumors are well-oxygenated. In some of these studies, either the timing of 
radiation delivery or administration of carbogen was used to increase tumor oxygenation during therapy, 
yielding two clinically-feasible approaches to improve the efficacy of radiotherapy.  
1.4 EPR oximetry in human subjects using ink 
We have demonstrated that oxygen measurements can be made in human subjects in superficial tumors 
using India ink. EPR oximetry measurements in human subjects were performed using a whole-body EPR 
spectrometer consisting of a 420-Gauss permanent magnet, magnetic field modulation and sweep coils, 
RF detection system including surface-loop resonators, and computer control. The spectrometer operates 
at an L-band frequency (~1.2 GHz), where a practical compromise between RF penetration depth and EPR 
sensitivity is achieved. At this frequency, RF penetration depths of approximately 10 mm are achieved. We 
have obtained pO2 data in superficial tumors at different sites in cancer patients and healthy volunteers. 
Our initial measurements in human subjects used India ink as an oxygen sensor and under conditions that 
could readily be incorporated into normal clinical processes. The ink was inserted into the tumors or other 

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DH 
Study 
ID 
Diagnosis 
Location of 
OxyChip 
Implantation 
Treatment 
Prior to 
OxChip 
Removal 
Max 
AE 
Description 
AE 
UADE 
Location of 
OxyChip on 
microscopic 
evaluation 
Pathologic 
Findings 
Associated 
with OxyChip 
Pathologic  
Expectations 
in Context of 
Implantation 
Event 
1735 
Lipoma 
Upper left 
back, 
subcutaneous 
None 
0 
NA 
No 
Not within 
tumor; within 
superficial 
fascia of 
subcutaneous 
mass 
Mild 
macrophage 
predominant 
chronic 
inflammatory 
reaction at 
needle site 
Anticipated 
1746 
Melanoma 
Left anterior 
tibia, skin 
None 
1 
Minor 
bleeding 
from 
implantation 
needle 
No 
Within tumor 
Minor 
hemorrhage 
at site of 
injection 
Anticipated 
1747 
SCC Skin 
Left nasal 
dorsum, skin 
None 
0 
NA 
No 
Within tumor 
Mild 
macrophage 
and foreign 
body type 
giant cell 
reaction at 
OxyChip site 
Anticipated 
1748 
Melanoma 
Scalp, skin 
None 
1 
Pruritis,  
scalp 
No 
Within tumor 
Tumor 
necrosis and 
mild 
hemorrhage 
immediately 
Anticipated 
)LJXUH5HPRYDORIDQ2[\&KLSIURPDUHVHFWHG
WXPRUVXEPDQGLEXODUO\PSKQRGHVTXDPRXVFHOO
FDUFLQRPDIURPSDWLHQW7KH2[\&KLSEOXH
DUURZLVZLWKLQWKHWUDQVHFWHGWXPRUVSHFLPHQ
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EUHDVWPDOLJQDQF\RIDSDWLHQWXVLQJD
IOH[LEOHUHVRQDWRUSODFHGRYHUWKHWXPRU

EPR Oximetry using OxyChip 
 
Page 16 
 
CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
adjacent to 
injection site 
1749 
BCC 
Left temporal 
scalp, skin 
None 
1 
Pruritis  
No 
Within tumor 
Minor focal 
hemorrhage 
seen adjacent 
to the deep 
margin. Very 
focal 
collection of 
macrophages. 
Anticipated 
1750 
SCC Skin 
Scalp, 
posterior 
superior, skin 
None 
0 
NA 
No 
Not found, 
presumed 
lost prior to 
surgery due 
to rapidly 
progressive 
tumor 
necrosis 
NA 
NA 
1752 
SCC Skin 
Right 
posterior 
triangle neck, 
subcutaneous 
mass 
None 
1 
Discomfort 
at surgical 
site 
No 
Outside of 
and adjacent 
to  tumor  
within dermis 
Focal 
disrupted 
tissue at edge 
of tumor with 
mild 
nonspecific 
chronic 
inflammation 
Anticipated 
1758 
FTC 
Thyroid 
None 
0 
NA 
No 
Within tumor 
No reaction 
NA 
1760 
SCC Skin 
Frontal Scalp, 
Left, skin 
None 
0 
NA 
No 
Within tumor 
No reaction 
NA 
1764 
SCC Skin 
Infraorbital 
cheek, Left, 
subcutaneous 
None 
1 
Minor 
bleeding 
from 
implantation 
needle 
No 
Adjacent to 
tumor, but 
not within 
tumor; 0.4 
cm  from 
tumor margin 
Focal 
organizing fat 
necrosis 
Anticipated 
1765 
SCC Skin 
Right 
temporal 
scalp. Skin 
None 
1 
Minor 
bleeding 
from 
implantation 
needle 
No 
Within tumor 
No reaction 
NA 
1768 
 SCC Skin 
Right Neck, 
level II lymph 
node 
None 
1 
Minor 
bleeding 
from 
implantation 
needle. Mild 
bruising. 
No 
Within tumor 
Cystic 
degeneration 
of tumor 
Anticipated 
1770 
IDC 
Right Breast 
None 
1 
Minimal 
bleeding 
associated 
with 
implantation.  
Mild bruising 
at needle 
insertion 
site. 
No 
Within tumor 
No reaction 
NA 
1779 
IDC 
Left Breast 
None 
1 
Minor 
bleeding 
from 
implantation 
needle. 
No 
Not within 
tumor, 1  mm 
from tumor 
edge 
Minimal fat 
necrosis, 
macrophage 
infiltrate 
immediately 
Anticipated 

EPR Oximetry using OxyChip 
 
Page 17 
 
CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
Minor 
bruising 
surrounding 
the OxyChip 
1761 
IDC 
Left Breast 
Chemotherapy 
1 
Mild 
discomfort 
from 
implantation 
No 
Uncertain 
relationship 
to 
pretreatment 
tumor 
No reaction 
NA 
1762 
IDC 
Left Breast 
Chemotherapy 
1 
Mild 
discomfort 
and bleeding 
from 
implantation 
procedure. 
Bruising from 
implantation 
needle. 
No 
Uncertain 
relationship 
to 
pretreatment 
tumor 
No reaction 
NA 
1771 
IDC 
Left Breast 
Chemotherapy 
1 
Minor 
bleeding 
associated 
with 
implantation. 
Minor 
bruising near 
needle 
insertion 
site. Mild 
discomfort of 
left breast, 
not 
specifically 
associated 
with area of 
implantation. 
No 
Uncertain 
relationship 
to 
pretreatment 
tumor 
No reaction 
NA 
1780 
Sarcoma 
Right Chest 
Wall 
Radiotherapy 
1 
Minor 
bleeding 
from 
implantation 
procedure 
that resolved 
minutes 
after the 
completion 
of the 
procedure 
No 
Within 
collagenous 
soft tissue 
skeletal 
muscle fascia 
outside of 
viable tumor 
at least 6 mm 
No reaction 
NA 
1781 
IDC 
Right Breast 
Chemotherapy 
1 
Bleeding at 
needle 
insertion site 
No 
Uncertain 
relationship 
to 
pretreatment 
tumor 
Focal fibrosis, 
few 
macrophages 
  
1782 
IDC 
Left Axillary 
Node 
Chemotherapy 
0 
NA 
No 
No residual 
tumor 
No reaction 
NA 
1783 
IDC 
Right Axillary 
Node 
None 
1 
Bruising at 
implantation 
site 
No 
Within tumor 
 Focal 
fibrosis, 
macrophages, 
and apparent 
tumor 
capitation. 
Likely a 
function of 
tumor 
integrity and 
not 
abnormality 
Anticipated  

EPR Oximetry using OxyChip 
 
Page 18 
 
CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
in procedure. 
Tumor at the 
edge of the 
cystic cavity is 
viable and 
unaffected 
1784 
SCC Skin 
Above 
manubrium, 
skin  
None 
1 
Bleeding 
from 
implantation  
No 
Unclear 
Tumor 
necrosis 
within chip 
site 
  
1785 
SCC Tonsil 
Level II LN, 
neck 
 None 
1 
Pain and 
bleeding 
from 
implantation 
No 
Within tumor 
No reaction 
NA 
 
 
The resected tissues showed no signs of infection. There was evidence of an inflammatory response 
associated with expected trauma along the needle track from the implantation itself. In a few patients, a 
typical foreign body reaction was evident. As graded by the pathologist (J.P.) no findings indicative of 
significant, clinically concerning inflammation or reaction were found in any patient.  In addition, via clinician 
assessment, no patients had any significant clinical toxicity associated with the implantation procedure or 
the presence of the OxyChip itself. The maximum CTCAE toxicity grade was 1.0.   
Phase 1A and 1B still require removal of the OxyChip . However, it is important to note that based on the 
above safety data the FDA has now given permission to proceed with evaluation of permanent implantation 
of the OxyChip.  
1.5.3 pO2 measurements 
To date, we have made a total of >60 pO2 measurements. The pO2 values successfully measured (Figure 
7) from the patients, on multiple visits, are shown in Table 1. In each session, where an EPR signal from 
the OxyChip could be detected, pO2 measurements were made continuously for 5-10 min while the patient 
breathed room air, followed by 10 min of breathing 100% oxygen, and then for 10 min after the patient had 
returned to room-air breathing. The tumor pO2 values showed varying degrees of hypoxia and response to 
hyperoxygenation (Figure 8). The EPR signal could not be detected in some patients. Ultrasound imaging 
revealed that the OxyChips in these tumors were deeper (10-16 mm) than the usual depth in other tumors, 
which may explain our inability to obtain an EPR signal. 
1.5.4 Integrity and calibration of OxyChip 
All the explanted OxyChips were morphologically intact, except in 2 cases in which the chip was cut during 
removal from the excised tumor in the pathology lab. The oxygen-sensing calibration of the explanted chips 
was unchanged from the pre-implant calibration, suggesting that the oxygen-sensing ability of the chip was 
unaffected during its residency in the tissue for more than 4 months. 
1.5.5 Compliance with FDA and Dartmouth IRB regulation 
We have obtained approval from the FDA (Investigational Device Exemption) and the Dartmouth IRB 
(CPHS) to increase the total number of enrollments from the initial cohort of 12  to 60 patients, and to extend 
Table 1: Summary of toxicity for first 23 patients.  Maximum adverse events (AE) were graded using 
CTCAE v4.0. Abbreviations: SCC = squamous cell carcinoma; BCC = basal cell carcinoma; FTC = 
follicular thyroid cancer; IDC = invasive ductal carcinoma; AE = adverse event; UADE = unanticipated 
adverse event;  

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the length of OxyChip residence in the tumor for up 
to 1 year. Currently, we have completed the Phase 
1 safety and efficacy study requirement set by the 
FDA.  
1.5.6 Summary 
Safety: For the patients enrolled to date, we did not observe any reportable toxicity (grade 3 or higher 
according to the Common Terminology Criteria for Adverse Effects (CTCAE)) caused by the implanted 
OxyChips. We did not observe any unanticipated adverse device effects (UADE).  The EPR measurements 
demonstrated that the OxyChip is robust and capable of making direct and repeated measurements of pO2 
for weeks and months without toxicity or change in oxygen sensitivity. Specifically, the measurements 
demonstrated the ability of the chip to measure tumor pO2 values during room-air breathing and 
hyperoxygen intervention. The tumors showed variable responses to 100% O2 breathing, with most tumors 
showing a positive (increase of pO2) response to hyperoxygen intervention, while some tumors showed 
minimal response. Figure 8 shows a complete listing of pO2 data obtained from 39 measurements. Overall, 
the results indicated that the pO2 values are both tumor-type and time dependent suggesting the importance 
of personalized and real-time measurement. 
 
 
Overall, the initial clinical measurements suggest that the OxyChip is robust and capable of making direct 
and repeated measurements of pO2 for weeks without toxicity or change in oxygen sensitivity. Specifically, 
measurements in the first cohort of surgical cancer patients demonstrated the ability of the chip to measure 
tumor pO2, whose values ranged from severely hypoxic (~1 mmHg) in an SCC tumor to well oxygenated 
(~24 mmHg) in a lipoma, under baseline conditions. The tumors showed variable responses to 100% O2 
breathing (via face mask). Histopathological evaluation of the excised tissues revealed no unexpected 
inflammation or hemorrhage at the site of the OxyChip implantation.  
 
 
 
 
Figure 8, Tumor pO2 values in patients breathing room air (Base value) and 100% oxygen 
(Oxygenation). The pO2 values, measured from a total of 13 patients, are included in the plot. Multiple 
measurements from the same patient are indicated by each bar on the bottom. Below this bar is the total 
amount of days that the OxyChip was implanted. The data ranging from 0 to 10 mmHg is shaded to 
indicate the generally accepted hypoxic range. All data represent Mean±SEM. Significance compared to 
corresponding base value: * p<0.05; ** p<0.01; *** p<0.001. 

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1.6 Justification of cohort design and revisions of the protocol 
1.6.1 Rationale for expanding Phase 1A and Phase 1B Cohorts  
Pilot studies for medical devices are intended to test the initial design of the device and procedures. It is 
expected that device modifications or procedure modifications will be made based on the experience of 
various providers in real clinical scenarios during the testing phase. The following are some reasons for 
conducting a pilot study for medical devices and how a larger study (i.e., a more typical pilot study size of 
up to 30 patients) will be important for studying the safety and performance of the OxyChip. 
We will initiate Phase 1A (oxygen measurements without therapy planned prior to surgical resection) with 
two cohorts of 3 patients. The table below provides justification to expand the Phase 1A study from these 
two cohorts of 3 patients to then enroll an additional 24 patients if no unacceptable toxicities including 
unanticipated adverse device effects (UADE) occur in the first 6 patients.  
 
Goal 
Phase 1A - 6 patient 
study 
Benefit to expanding the study 
Help address 
specific safety 
concerns 
The initial 6 patients 
suggest safety of the 
device and study 
procedures in pre-surgical 
patients, but the study is 
small.  
Increasing the Phase 1A to 30 patients will 
provide additional safety information for pre-
surgical patients prior to proceeding with either a 
“Pivotal” study or a study combining oxygen 
measurements with an oxygen treatment for a 
therapeutic stud.  
Permit initial 
assessment of 
device design 
Initial device design 
suggests that the device 
and procedures are well 
tolerated. 
Additional designs of the EPR measuring device 
(not in the OxyChip itself) are planned to help 
identify the OxyChip more efficiently in patients 
and in tumor specimens.  
Better define/refine 
the clinical 
endpoints and 
intended patient 
population 
 
Additional patients will allow more measurements 
of specific tumor types (e.g., skin SCC, 
melanomas and SCC of the head and neck 
region) to collect baseline pO2 and oxygen 
responsiveness in larger cohorts of these tumor 
types. 
Provide 
investigators with 
initial device 
experience and 
identify special 
training needs 
All injections were 
performed by only two 
clinicians, Dr. Chen and 
Dr. Jarvis. 
Expanding the trial will allow more investigators to 
be trained in injection procedures. Specifically, Dr. 
Schaner will be trained to perform injections. 
Estimate the 
required patient 
population size 
 
Larger cohort of similar patients will allow for more 
accurate power calculation for larger “Pivotal” or 
therapeutic trial.  
 
In a similar design strategy, we will  initiate Phase 1B (oxygen measurements during either standard 
chemotherapy or radiotherapy prior to surgical resection) with one cohort of 3 patients receiving 
radiotherapy and one cohort of 3 patients receiving chemotherapy. Only after a full evaluation of 3 patients 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
receiving chemotherapy will additional patients receiving chemotherapy be enrolled. Similarly, only after a 
full evaluation of 3 patients receiving radiotherapy will additional patients receiving radiotherapy be enrolled. 
The two cohorts in Phase 1B are independent of each other, so either of these cohorts may continue accrual 
after the initial 3 patients while the other is still accruing the initial 3 patients. A total of 30 patients will be 
enrolled in Phase 1B.   
1.6.2 Rationale for increasing the duration of residency of the OxyChip in a tumor  
Patients in the first 2 cohorts of 3 patients in Phase 1A were implanted with the OxyChip for up to 32 days 
and monitored post explantation. No unacceptable toxicities or unanticipated adverse device effects were 
observed during or after study procedures. This indicated that the OxyChip is safe and does not elicit any 
reaction or undesirable effect on the host tissue. Based on these initial results and the need for monitoring 
patients for longer periods, especially those receiving radiation or chemotherapy treatments, it is desirable 
to keep the implant for longer periods until the treatment is completed. This is also important if the schedule 
for surgical resection of the tumor changes after implantation of the chip. We have completed safety and 
efficacy studies of OxyChips implanted in rat muscle and measured in vivo for 52 weeks. The results 
showed stable and repeated EPR oximetry measurements over the 52-week period without any toxicity or 
undesirable effects to the host tissue. The chip was intact with stable EPR and oxygen sensitivity. Hence, 
we requested and received approval for the OxyChip to be implanted in the patients’ tumors for up to 52 
weeks  before removal during routine surgical resection. 
1.6.3 Rationale for the option of implanting fiducials with the OxyChip 
In order to assist with locating the OxyChip during treatment, during EPR measurements, and during/after 
resection, the protocol was revised to allow for fiducial(s) (either one or two) to be implanted along with the 
OxyChip during the procedure. The decision to implant fiducials is at the discretion of the investigator. 
  
Because tumors size and shape can change during the course of radiation, the location of the OxyChip in 
relationship to the tumor may also change. By implanting fiducials with the OxyChip, the location of the 
OxyChip will be able to seen on CT scans that patients intermittently receive during radiation treatment as 
part of clinical care. This will allow for better interpretation of the pO2 measurements that are collected 
throughout the treatment, as the location of the OxyChip in relation to tumor tissue will be evaluable.  
 
Adding fiducials will also assist in locating the OxyChip for EPR measurements. Although OxyChips can be 
located in vivo using ultrasound guidance, it can be challenging to do so; fiducials can be located quicker 
than the OxyChip implanted alone and with higher sensitivity. This allows for faster placement of the 
resonator, which facilitates faster oxygen measurements. This is of great importance in the clinical 
translation of EPR oximetry, where time is limited.  
 
Fiducials will also assist in procedures during and after resection. In order to assure that the OxyChip has 
been explanted, the pathology specimen will be scanned prior to surgical closure in the pathology lab. If 
the implanted fiducial(s) are located in the resected specimen, then there is high confidence that the 
OxyChip has been successfully explanted (See section 5.2.4 for more information on this procedure). 
Fiducials can also assist with assessing the pathology specimen after resection to ensure that the OxyChip 
is not cut during the dissection of the specimen, and to rapidly identify the location of the OxyChip in the 
specimen. If two fiducials are implanted, the orientation of the OxyChip will be known, so the pathologist 
will cut parallel to the two fiducials in order to not cut the OxyChip in the process.  
 
A study has been completed where an OxyChip was successfully implanted into a phantom with two 
fiducials on each side of it in a number of different substrates without difficulty. EPR oximetry data in a 
known oxygen concentration was also collected from the OxyChip with and without fiducials present. These 
results showed that the presence of the fiducials had no significant effect on the pO2 measurements (Figure 
9). 
 
   
  

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The use of fiducials in the radiation oncology clinic is standard of care in a number of malignancies. For 
example, in order to facilitate image guidance daily during radiotherapy for prostate cancer the radiation 
oncologist places two to three fiducials into the prostate prior to treatment under ultrasound guidance in the 
clinic. These fiducials remain in place permanently after treatment. In the OxyChip protocol, the fiducials 
will be removed.  
 
1.7 Risk/Benefits 
In this Phase 1 Safety clinical trial, there are no expected benefits to the patients. The benefit is for those 
patients who have a desire to advance this technology and/or to improve radiotherapy for future patients. 
Furthermore, the knowledge gained by repeated measurement of tumor oxygen levels, especially during 
radiotherapy is critical for developing and implementing novel hypoxia-targeting therapies. 
The risks are expected to be minimal. As with any implantation, there is a risk of pain, bleeding or infection. 
We expect this risk to be minimal and not more than the risk of a core needle biopsy, since the implantation 
procedure is minimally invasive, and performed with a needle insertion. Risks associated with placement 
beyond the risks associated with placement of the OxyChip itself are expected to be minimal. There is a 
very low risk of fiducial migration, estimated at 0.35% in one study of prostate cancer and fiducial placement 
211. Over 1000 fiducials have been implanted into patients in the Radiation Oncology clinic at DHMC as part 
of routine clinical care for prostate cancer with no significant complications (Alan Hartford, personal 
communication). Patients are consented for placement of fiducials in addition to the OxyChip. There is an 
unknown risk from LiNc-BuO in humans; however, no toxicity is expected based on studies using animal 
models and because the LiNc-BuO crystals are embedded in biocompatible PDMS to further eliminate any 
potential risk. Furthermore, the biocompatibility of OxyChips has been established in pre-clinical studies for 
Figure 9: Effect of fiducials on OxyChip pO2 measurements. An OxyChip was inserted into a nitrogen 
flow tube and EPR oximetry was performed (“no markers”). The same experiment was repeated with 
two fiducials flanking the OxyChip. No significant difference in pO2 was noted, indicating no effect of the 
present of the fiducials on OxyChip derived pO2 measurements.  
0.42
0.20
0.08
0.07
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
No markers
Gold Spheres
Gold Coils
Polymarks
pO₂ (mmHg)

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up to 52 weeks and, to date, in humans for up to 141 days with approval to be implanted for up to 52 weeks. 
In addition, the OxyChips will be placed in superficial locations and will be removed in this protocol when 
the tumor is resected. There is a possibility that the patient might be in an uncomfortable position during 
oxygen measurements, but re-positioning can be performed at any time if needed.  
The study population will consist of patients who are ≥ 18 years of age, both genders, and must be 
competent to consent to participate in the trial. Risks of the device will be minimized by placement of the 
device under sterile conditions using a minimally-invasive procedure. The implantation site will be monitored 
closely.  
2 Study Objectives 
2.1 Primary Objective 
This is a safety study to demonstrate that the implantation procedure, the OxyChip, and any subsequent 
oxygen measurements will be well-tolerated by the patient with minimal risk for complications. Specific 
adverse effects that will be monitored include:  
• 
Allergic reactions or signs of inflammation at the site of implantation or systemically 
• 
Infection at the site of implantation 
• 
Bleeding at the site of implantation 
• 
All tumors will be excised with the OxyChip in place, and histology will be analyzed for signs of 
tissue reaction and inflammation adjacent to the OxyChip 
• 
Device (PDMS-embedded) breakage, loss of EPR or oxygen sensitivity, or change of calibration 
• 
Erosion of skin over the implantation site 
• 
Any unanticipated adverse device effects (UADE) will be assessed and reported. UADE will be 
defined as, “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, 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)). 
2.2 Secondary Objective 
This study will also determine the feasibility of repeated measurements of oxygen in tumors using the 
OxyChip and EPR oximetry. This objective is unrelated to the primary safety objective. 
• 
To assess the feasibility of making repeated measurements of tumor oxygen levels in patients 
with easily-accessible, superficial tumors. 
• 
To determine the tumor oxygen levels in patients without therapy prior to surgical excision 
(Phase 1A), or during a course of radiotherapy or neoadjuvant chemotherapy prior to surgical 
excision (Phase 1B).  
• 
To determine the workflow and time required for each daily oxygen measurement. 
2.3 Exploratory Objective 
Collection and future use of tumor tissue surrounding the implanted device will be done to analyze 
molecular biomarkers related to hypoxia, angiogenesis, and tumor growth. The tissue analysis will explore 
the potential for any identifying biomarkers of the tumor that predict or otherwise are associated with 
variation in tumor growth or responsiveness to therapy.  

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3 Study Design  
3.1 General Design 
This is a Phase 1 clinical trial. Total enrollment will be 60 evaluable patients. Evaluable patients will be 
defined as patients who have the OxyChip implantation for the minimum of 3 days.  
The study is split into Phase 1A (shorter duration of implantation with no other cancer therapy planned prior 
to excision) and Phase 1B (longer duration of implantation that is typically up to 12 weeks while receiving 
radiation therapy or longer if receiving neoadjuvant chemotherapy prior to surgical excision), as described 
below. OxyChip implant duration for both phases can be extended to 52 weeks (excluding the initial 6 
evaluable patients in Phase 1A which may have the OxyChip implanted up to 4 weeks). 
The initial 6 evaluable patients in Phase 1A will have the OxyChip placed for a short duration (up to 4 
weeks) after which the OxyChip will be removed when the tumor mass is resected, prior to delivery of any 
further therapies. After successful implantation and removal of the OxyChip without any unacceptable 
toxicity in the first 6 evaluable patients, the Phase 1A cohort will be expanded to a total of 30 patients. In 
order to complete the safety and toxicity assessment of the short-term implantations, we will require that at 
least 3 patients have OxyChip implantations for a duration of at least 2 weeks, prior to proceeding to Phase 
1B (long term implantation). This may require enrollment of additional patients in Phase 1A in order to meet 
this criterion. Phase 1B will consist of one cohort of 3 evaluable patients receiving chemotherapy treatment 
and one cohort of 3 evaluable patients receiving radiotherapy.  Only after a full evaluation of the first 3 
patients that underwent chemotherapy will additional patients receiving chemotherapy be enrolled. 
Similarly, only after a full evaluation of the first 3 patients that underwent radiotherapy will additional patients 
receiving radiotherapy be enrolled. The two cohorts of 3 patients in Phase 1B are independent of each 
other, so either of these cohorts may continue accrual after the initial 3 patients while the other is still 
accruing for the initial 3 patients. A total of 30 patients will be enrolled in Phase 1B. .  
This larger cohort will allow further assessment of safety, as well as optimization of procedures for the 
OxyChip placement and subsequent oxygen measurements for different tumor types in different anatomical 
locations. This expanded Phase 1 study will also achieve a secondary goal of increasing patient numbers 
for specific tumor types (i.e., melanomas, squamous cell carcinomas and sarcomas) to assess the levels 
of tumor oxygenation and their response to supplemental oxygen breathing.   
The phase 1B patients will have up to five oxygen measurements per week during the course of radiation 
or chemotherapy. Patients will be evaluated weekly during radiotherapy or prior to each chemotherapy 
administration or follow-up appointment for assessment of any adverse effects, as per the primary objective. 
Oximetry measurements will be taken periodically, from at least one day after implantation up to the 
OxyChip’s removal. The OxyChip will be removed at a planned surgery as part of standard-of-care therapy. 
Phase 1A patients will be evaluated at least monthly prior to OxyChip removal for assessment of adverse 
effects, again for the primary objective.  
If a patient cannot or does not return for an evaluation, the study team will contact the patient by phone or 
email to check for development of new adverse events or changes in health status. Assessments by non-
study physicians  or physician extenders as part of standard care are also an acceptable replacement, if 
the patient is not accessible for an in-person evaluation. Following resection, the tissue surrounding the 
OxyChip will be examined for any adverse effects, as per the primary objective. For the exploratory 
objectives, the tissue will also be examined for biomarkers associated with hypoxia or growth.   
 
Schema: 

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PHASE 1A 
 
Purpose 
Primary: Safety of the OxyChip placement procedure and OxyChip removal after 
short duration (typically less than 4 weeks, but up to 52 weeks). 
Secondary: Feasibility of taking repeated oxygen measurements using the 
OxyChip. 
Patient 
population 
There will be a total of 30 patients enrolled in Phase 1A. 
Initially, 3 patients will be enrolled; the OxyChip will be placed; physical 
examination of the site will be made periodically (at least in conjunction with visits 
where oxygen measurements will be made) starting from one day following 
implantation for up to 52 weeks – at which point the tumor will be resected with 
concurrent removal of the OxyChip. If no adverse events are noted in the physical 
exams or tissue pathology, an additional 3 patients will be enrolled in this phase of 
the study. The decision to start the second cohort of 3 will be made by the study PI 
after review of surgical pathology reports and after the first 3 evaluable patients 
are at a time point more than 2 weeks following surgical removal of the OxyChip. 
Next, if no unacceptable toxicity is noted after completion of the first 6 patients, the 
enrollment will be open to 24 more, for a total of 30 patients. (Note: the enrollment 
totals will include patients enrolled at DHMC or Emory University, once the 
addition of Emory as a participating site is approved.)   
In addition the following eligibility and exclusion criteria will apply:  
• 
Superficial tumors located ≤ 3 cm from skin or mucosal surface. 
• 
Surgical resection of the tumor is planned at least 3 days following 
implantation. 
• 
Eligible tumors for this phase of the protocol are any tumors that (a) 
are identified by imaging or physical exam to be superficial enough for 
OxyChip placement and (b) will receive surgical resection with intent 
to remove the entire tumor. 

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• 
Previous radiation to the site is not allowed. 
• 
Planned use of chemotherapy or radiation therapy or use of 
angiogenesis inhibitor prior to resection is not allowed.  
• 
Patients do not have to agree to an oxygen measurement in order to 
be eligible. Although oxygen measurements are desirable, the primary 
endpoint is safety of the OxyChip placement and removal over a short 
time frame. 
• 
Tumors must be > 2.5 cm in minimum diameter to be eligible.  
OxyChip 
placement 
Placement of OxyChip will be through a minimally invasive procedure (see 
methods for implantation protocol). 
OxyChip removal 
The OxyChip will be removed at the time of surgical resection, which will occur 
within 52 weeks from the time of implantation. Surgery date must be  at least three 
days after placement of the OxyChip. Tumor tissue surrounding the implanted 
device will be collected and examined for adverse events (primary) and stored to 
allow for future evaluation of molecular biomarkers (exploratory). 
Oxygen 
measurements 
The goal is for at least 2 oxygen measurements to be taken in the period between 
the day of OxyChip placement and removal (secondary objective). Note, however, 
that oxygen measurements are not necessary to determine the presence or 
absence of any unexpected adverse device events of implanting the OxyChip, for 
the study’s primary goal. 
 
 
PHASE 1B 
 
Purpose 
Primary: Safety of the OxyChip during neoadjuvant radiotherapy or neoadjuvant 
chemotherapy with planned surgical resection as part of standard oncologic 
therapy.  
Secondary: Feasibility of oxygen measurements during neoadjuvant radiotherapy 
or neoadjuvant chemotherapy using the OxyChip. 
Patient 
population 
There will be a total of 30 patients enrolled in Phase 1B. 
Phase 1B will consist of one cohort of 3 evaluable patients receiving chemotherapy 
treatment and one cohort of 3 evaluable patients receiving radiotherapy.  Only after 
a full evaluation of the first 3 patients that underwent chemotherapy will additional 
patients receiving chemotherapy be enrolled. Similarly, only after a full evaluation of 
the first 3 patients that underwent radiotherapy will additional patients receiving 
radiotherapy be enrolled. The decision to enroll additional patients in each cohort 
will be made by the study PI after review of surgical pathology reports and after the 
3 evaluable patients are greater than 2 weeks after surgical removal of the 
OxyChip. The two cohorts of 3 patients in Phase 1B are independent of each other, 
so either of these cohorts may continue accrual after the initial 3 patients while the 
other is still accruing for the initial 3 patients.  
 
In addition, the following eligibility and exclusion criteria will apply:  
• 
If a patient is to receive neoadjuvant chemotherapy or radiotherapy at a 
hospital other than DH prior to resection of the cancer at DH, patients 

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will still be eligible for enrollment as long as a PI or Co-PI on the study 
can evaluate the implanted site at least every two weeks during 
treatment. Of note, patients must receive their surgery at DH to be 
eligible. 
• 
Superficial tumors located ≤ 3 cm from skin or mucosal surface, where 
neoadjuvant radiotherapy or neoadjuvant chemotherapy followed by 
surgical resection is planned. 
• 
Eligible tumor histology for this protocol is any biopsy proven 
malignancy expected to undergo neoadjuvant chemotherapy or 
radiotherapy prior to resection  
• 
Previous radiation to the site is not allowed.  
• 
Use of angiogenesis inhibitors is not allowed.  
• 
Planned use of concurrent neoadjuvant chemoradiotherapy, or 
sequential neoadjuvant radiation therapy and chemotherapy, prior to 
resection, is not allowed. 
• 
Patients do not have to agree to an oxygen measurement in order to 
be eligible. Although oxygen measurements are desirable, the primary 
endpoint is safety of OxyChip during neoadjuvant radiation or 
chemotherapy. 
• 
Tumors must be > 2.5 cm in minimum diameter to be eligible. 
OxyChip 
placement 
Placement of OxyChip will be through a minimally invasive procedure (see methods 
for implantation protocol).  
OxyChip 
removal 
The OxyChip will be removed with the tumor mass at the time of surgical resection 
and examined for adverse events (primary goal). Tumor tissue surrounding the 
implanted device will be collected and stored to allow for future evaluation of 
molecular biomarkers (exploratory goal). 
Oxygen 
measurements 
The goal is at least two measurements prior to the start of radiation therapy and 
then up to five times per week during radiotherapy or chemotherapy for the 
secondary objective. Note, however, that oxygen measurements are not necessary 
for the study’s primary goal to determine the presence or absence of any adverse 
events after implantation of the OxyChip. 
3.2 Primary Study Endpoint 
For the primary objective (safety of the implantation procedure: the OxyChip itself and removal of the 
OxyChip is expected to be well-tolerated with minimal risk for complications). The primary endpoints will be 

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all grade 3 or higher toxicities according to the Common Terminology Criteria for Adverse Effects (CTCAE) 
that are attributed to the device or procedure.  
3.3 Secondary Study Endpoint 
For the secondary objective (feasibility of repeated oxygen measurements in tumors using the OxyChip 
and EPR oximetry) the secondary endpoint is completion of planned oxygen measurements. 
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
1. Phase 1A: Any tumor identified by imaging or physical exam to be accessable to OxyChip 
implantation and measurements and that is going to receive surgical resection with intent to 
remove the entire tumor. The tumor must be sufficiently large to accommodate the OxyChip. 
2. Phase 1B: Any biopsy-proven malignancy expected to undergo neoadjuvant chemotherapy or 
radiotherapy prior to resection. The tumor must be sufficiently large to accommodate the 
OxyChip. 
3. The tumor must be within 3 cm of the surface of the skin or mucosa. 
4. Age ≥18 years old. 
5. Subject must be capable of giving informed consent  
6. Anticipated time between implantation and planned surgical excision of at least three days. 
7. Tumors must be > 2.5 cm in minimum diameter to be eligible. 
4.2 Exclusion Criteria 
1. Pregnant women or women of childbearing potential without adequate contraception. 
Contraception, which can include abstinence, is required from the first day of the last menstrual 
period until the removal of the OxyChip. 
2. Receipt of concurrent chemotherapy and radiotherapy, or planned sequential chemotherapy and 
radiotherapy, prior to resection (Phase 1B),  
3. Receipt of Avastin, or other angiogenesis inhibitors, during the study. 
4. Prior radiotherapy to the site of implantation. 
5. Having other implanted (not removable) devices that generate electrical artifacts or that could be 
altered by the EPR magnetic field, such as cardiac pacemakers or defibrillators. 
6. Concurrent enrollment in any clinical research study, in the absence of cancer recurrence, in 
which the other study can reasonably be anticipated to have the potential for causing adverse 
events that would affect our primary endpoint of assessing the safety of the OxyChip device. If a 
study is not felt to impact the evaluation of adverse events in this trial then the patient will be 
eligible for concurrent enrollment. In the presence of confirmed clinical recurrence after initial 
cancer therapy (and after removal of OxyChip) during the year-long follow up stipulated in the 
protocol, patients will be eligible for all clinical trials as deemed appropriate by the treating 
oncologist.  
7.  Patient platelet blood count < 50,000/l of blood, and absolute neutrophil count < 1,000/l of 
blood. Laboratory values must be obtained at least 3 months prior to implantation of the OxyChip.  

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4.3 Subject Recruitment and Screening 
Patients will present to one of the DHMC surgical, medical or radiation oncologists who will review the case. 
If the patient meets criteria for enrollment and the surgeon is planning tumor resection, the case will be 
reviewed with the PI or a co-investigator to determine suitability for enrollment. The patient will then be 
recruited and consented by the PI or one of the co-investigators in collaboration with the treating surgical, 
medical or radiation oncologists.  
Patient enrollment will be entered into the Velos eResearch Database.  
The study will not be advertised. 
Screening requirements for the study: 
1. Any imaging of the tumor (including ultrasound, MRI or CT scans) must be available for review to 
guide the OxyChip implantation. A radiation-therapy-planning CT scan may be used to meet this 
requirement in Phase 1B. For patients with tumors involving the skin, which are easily visualized 
and palpated on clinical exam, imaging is not required. This requirement will be determined by PI 
and surgical oncologist, but in general, will be consistent with standard practice for surgical 
planning for each tumor. 
2. Physical examination. 
3. Pregnancy test, if applicable, within 14 days of OxyChip implantation. 
4.4 Early Withdrawal of Subjects 
4.4.1 When and how to withdraw subjects 
A subject may be withdrawn from the study at any time at the discretion of the treating physicians or if the 
patient withdraws consent. If the OxyChip was placed before withdrawal, there will be two options for 
withdrawing from the study, as follows: 
1. Discontinuing the oxygen measurements: Repeated oxygen measurements will be stopped at the 
patient’s request for any reason. The reason will be recorded and tracked as part of the study 
feasibility outcome. Under these circumstances, the OxyChip will not be immediately removed. 
Preferably, the OxyChip will be removed at the time originally planned when the tumor is 
resected. 
2. Removal of the OxyChip: The OxyChip may be removed at any time at the patient’s request. If 
the patient wishes to withdraw completely from the study, then the OxyChip will be removed. The 
OxyChip will also be removed early if there is an adverse event associated with the implant or if it 
is having (or may have) an adverse effect on the patient. This will require either surgical excision 
of the OxyChip or an en bloc surgical resection of the tumor with inclusion of the OxyChip. The 
type of surgery that is performed will be at the discretion of the surgical oncologist. 
4.4.2 Data collection and follow-up for withdrawn subjects 
Survival data will be collected on all patients for up to a year following implantation, including subjects 
withdrawn from the study following implantation. Survival data will be collected from the social security 
death index as well as the DHMC medical record. In addition, the reasons for early withdrawal will be 
collected to determine if the device or measurement procedures contributed to the early withdrawal. 
5 Study Device  
5.1 Description 
The device, OxyChip, used in this study is made in-house using a two-step process. In the first step, LiNc-
BuO crystals are synthesized using commercially available starting materials. In the second step, the LiNc-

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
BuO crystals are embedded in PDMS, a biocompatible polymer. The product is made in the form of a 
cylindrical pellet (0.6-mm diameter and 5-mm length) for implantation. 
5.1.1 Materials used for fabrication 
LiNc-BuO crystals are synthesized using the published procedure99. The method uses lithium granules, 
5,9,14,18,23,27,32,36-octa-n-butoxy-2,3-naphthalocyanine (Nc-BuO), n-pentanol, n-hexane, and tert-butyl 
methyl ether, all purchased from Sigma-Aldrich Chemical Co (St. Louis, MO, USA). PDMS is a medical 
grade silastic polymer (A-103) from Factor II, Incorporated (Lakeside, AZ).  
5.1.2 Synthesis of LiNc-BuO crystals 
Lithium granules (0.0053 g, 0.774 mmol) are added to n-pentanol (15 ml) and refluxed for 30 min under 
nitrogen atmosphere. The mixture is cooled to room temperature and Nc-BuO (0.1 g, 0.0774 mmol) is 
added and refluxed gently for 2.5 hours under nitrogen atmosphere. After cooling down to room 
temperature, 300 ml of tert-butyl methyl ether is added and filtered through a small silica gel plug. The 
solvent is then evaporated under reduced pressure to 3 ml of solution. The concentrate is dissolved in 100 
ml of n-hexane. The greenish solution is slowly evaporated under reduced pressure to yield shiny crystals 
of lithium 5,9,14,18,23,27,32,36-octa-n-butoxy-2,3-naphthalocyanine (LiNc-BuO). The crystals are washed 
with methanol and dried under a vacuum. Please see Attachment 2 for details of LiNc-BuO synthesis. 
5.1.3 Method for fabrication of OxyChip 
OxyChips are fabricated by cast-molding and polymerization, as reported102. The silastic polymer is mixed 
at the recommended base-to-crosslinker ratio (10:1), and crystals of LiNc-BuO are thoroughly dispersed 
into this mixture using a spatula. The base-crosslinker/LiNc-BuO microcrystal mixture is poured into a 
polystyrene weighing boat and degassed under vacuum. The degassed mixture is cured in an oven at 70°C 
for 3.5 hours. Please see Attachment 2 for details of SOP for fabrication of OxyChips. 
5.1.4 Sterilization 
As a “critical device” (i.e., a device that is introduced into a sterile area of the body), each OxyChip is 
sterilized with a SAL of 10-6 and validated as per the published standard (Sterilization of health care 
products – Moist Heat – Part 2: Guidance on the application of ANSI/AAMI/ISO 17665-1; TIR17665-
2:2009). The sterilization procedure is performed by trained staff, using the clinical autoclaves and standard 
procedures. Sterilizations are recorded. Individual OxyChips devices are placed in sealable autoclave bags 
with process indicators and are labeled with product identification number. The steam sterilization is done 
in the autoclave at gravity cycle (at 121oC (249.8oF)) and 15 PSIG for 30 minutes. The sterilization cycle is 
validated using biological indicators (BI) and chemical indicators (CI). If the indicator results are appropriate, 
the implant is released for use. The implant will remain sterile in storage as long as the integrity of the 
package is maintained. Importantly the device chemistry (PDMS and LiNc-BuO) is stable under high 
temperature conditions. (See Standard Method 67.0 for further details.) 
5.1.5 Calibration of oxygen sensitivity 
Prior to autoclaving, each OxyChip is calibrated. Each chip is placed individually in a 5-mm diameter NMR 
tube (Norell) modified for gas delivery. A calibration line is generated using the measured linewidths 
collected from an L-band EPR spectrometer under known conditions. EPR Linewidths are plotted relative 
to the % oxygen exposure to obtain the calibration curve, which is used to calculate pO2 from the measured 
linewidths using the corresponding samples implanted within the tumors. In addition, after each chip is 
implanted and subsequently excised along with the tumor, the OxyChip is re-calibrated and the pre- and 
post-implants are compared. 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
5.2.2 Oxygen measurements 
Patients will be positioned in the whole-body clinical EPR scanner located on the second floor of DHMC in 
Radiation Oncology (Figure 7A). The scanner is equipped with an electromagnet, and a translating bed, or 
chair, that facilitates rapid repositioning of measurement subjects. This magnet has a pole separation of 50 
cm, suitable for measurement in humans.  
An external loop resonator will be positioned on the skin surface (Figure 7B) above the OxyChip. Portable 
ultrasound may be used to assist in finding the OxyChip in order to facilitate the placement of this. 
Ultrasound imaging may be performed by trained Radiology staff or one of the trained study team members.   
EPR measurements will be performed using standard data collection procedures, collecting multiple EPR 
spectra and converting the observed absorption linewidths to pO2 using pre-established calibration curves. 
If the patient agrees to breathing 100% oxygen, the measurement will be divided into three, continuous, 
approximately 10-minute time periods (Baseline- patient breathing room air, Hyperoxygenation- patient 
breathing pure (100%) oxygen, Recovery- patient return to breathing room air). If the patient is unwilling to 
breathe 100% oxygen, data associated with baseline tumor oxygen will be collected. Any measurement 
may be concluded prior to completion at any time at the discretion of the operator/physician/patient.  
See Standard Method 68.x for further details regarding oxygen measurements.  
The time from patient positioning to completion of the last measurement will be recorded for each reading.  
Dartmouth’s IRB, in reviewing two other protocols using the same clinical EPR scanner to make oxygen 
measurements (CPHS 12459 and CPHS16578), has previously determined that the EPR scanner presents 
a non-significant risk and therefore does not require an IDE process for its use for investigational purposes. 
See Standard Method 68.x for further details.) 
5.2.3 Safety of EPR measurements 
Our clinical EPR scanner1 shown in Figure 7 operates at ~430 G (0.043 T) magnetic field strength and 
~1.2 GHz microwave energy as the RF source. The field is very low compared to whole-body clinical MRI 
scanners that operate typically at 1.5T or 3T magnetic field strength. The 1.2 GHz RF source in our clinical 
EPR scanner will use <20-mW power continuously when turned on for a few minutes (2-5 minutes). The 
maximum specific absorption rate (SAR) in the tissue at the position that should have the greatest density 
of RF, directly under the loop of the surface-loop resonator, has been estimated to be 3.7±1.2 W/kg at 100 
-mW incident 1.2 GHz RF power using a surface-loop resonator with an efficiency of about 0.1 mT/W1/2 210. 
This estimated value is substantially below the recommended limit (12 W/kg) in the relevant regulation for 
 
1 Note that this is the same EPR scanner as used in the protocol CCRC D0626/CPHS #12459 previously approved 
by Full Committee Review of CPHS. 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
extremities. Thus, the SAR for our measurements, even at 100-mW power, is well within the acceptable 
range for human applications. The protocol for our clinical EPR scanner will not use rapidly changing 
magnetic field gradients such as those used in MRI. However, the EPR measurements use three types of 
magnetic fields that change in time during the measurement: 
1. Main magnetic field sweep: The sweeping of the main magnetic field is done at slow rates, typically a 
linear sweep of 8 G over a 30-sec period, which translates to a rate of ~3x10-5 T/sec.  
2. Modulation field: We typically use a modulation field of 1 G or less at 20 kHz, which will amount to 
2T/sec.  
3. Multisite oximetry: We apply a static gradient magnetic field which will be applied during the entire 3-
sec duration of data acquisition. 
In all three scenarios, the rate of change of the magnetic field is well below the limit of 20 T/sec set by the 
1988 or 1995 Magnetic Resonance Diagnostic Devices (MRDD) Guidance. Hence the time-rate of change 
in the magnetic field is not expected to have any significant effect on the subject. 
5.2.4 OxyChip and Fiducial removal 
The OxyChip and fiducial(s) will be excised with the surgical specimen. The surgeon determines the timing 
of surgery, but it will typically be planned to be within 4 weeks for Phase 1A, or after completion of 
radiotherapy or chemotherapy for Phase 1B, although the OxyChip may remain implanted for up to 52 
weeks for both Phases (excluding the first 6 patients enrolled into Phase 1A). The minimum time from 
implantation to surgical excision required for inclusion is 3 days. Note, patients in Phase 1B are expected 
to have the OxyChip in place for a minimum of 5 weeks (the expected duration of radiation therapy). The 
protocol and goals for removal will be as follows: 
(i) 
 All attempts will be made to maintain the OxyChip in the tissue specimen, without disrupting 
the shape or position within the tumor mass. 
(ii) 
In collaboration with the surgeon, after the patient has been anesthetized, imaging of the 
fiducial(s) will occur prior to surgery in order to identify the putative location of the OxyChip and 
facilitate surgical removal. 
a. We anticipate the fluoroscopy will be sufficient for identification of the fiducial prior to 
surgical removal (and after). However, due to concerns that more advanced imaging may 
be necessary, the first three patients with fiducial implantation will have their surgery 
performed at DHMC in the Center for Surgical Innovation (CSI). If fluoroscopy is sufficient 
for identification, then subsequent surgeries can be performed in standard operating rooms 
as desired if fluoroscopy is available for identification of fiducials before and after surgery.  
i. In the first three patients in the CSI, if the fiducial is not found prior to surgery either 
CT or MRI imaging will be performed to identify the fiducials. If the fiducials are 
found within the expected surgical field, or reasonably adjacent, fiducials will be 
removed during surgery. If the fiducials are found in an unanticipated area, 
consultation between the PI and the surgeon will occur as to whether surgical 
resection is acceptable. All decisions regarding surgery will be at the discretion of 
the surgeon. If no fiducials are found after advanced imaging prior to surgery, then 
surgery will proceed as planned as all reasonable measures will have been taken 
to identify the location of the OxyChip at that time.  
b. After surgical resection, fluoroscopy will be performed on the specimen prior to surgical 
closure in order to ensure that the fiducials have been removed. If the fiducials are present 
in the specimen, it is highly likely that the OxyChip has been removed and surgical closure 
will occur. If the fiducials are not found then advanced imaging via CT or MRI will occur to 
attempt to identify the fiducials in the patient. If the fiducials are then identified, in 
consultation with the surgeon, that area will be removed if it is deemed acceptably close to 
the surgical field.  If the fiducial is not visualized, a discussion will be had with the surgeon 
regarding further excisions of margins, as well as a search of the surgical field for an 

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CONFIDENTIAL CPHS 28499 version 8 – October 10, 2019 
OxyChip/fiducial that may have fallen out at the time of surgery. In this circumstance, all 
attempts will be reasonably made to ensure removal of the OxyChip, but the surgeon will 
have discretion about what is clinically appropriate.   
If a definitive surgery is deemed unnecessary after chemotherapy therapy or radiotherapy 
(Phase 1B), or if a definitive surgery is delayed beyond the expected time point (> 52 weeks) 
due to unforeseen circumstances, the OxyChip may be removed in a minor procedure under 
local anesthesia. The OxyChip will be identified using the fiducials as surrogates via ultrasound 
or fluoroscopy, and that area will be excised using similar considerations noted above. This 
procedure will be performed at the first available time deemed safe for the patient as 
determined by the primary oncology team. 
In the circumstance where a patient dies prior to surgery and the OxyChip is still in place, a discussion will 
be had with the next of kin regarding removal of the OxyChip prior to burial. If next of kin agrees to allow 
OxyChip removal, it may be removed via a small surgical procedure.  
5.2.5 Tissue processing 
For the primary goal, immediately after tumor resection, the OxyChip will be removed from the tissue and 
inspected visually to confirm that the device remained intact. The tissue at the site of the OxyChip will be 
submitted for processing with standard DHMC pathology procedures. Tissue sections spanning the 
OxyChip placement site will be stained with hematoxylin and eosin and evaluated for the presence of acute 
or chronic inflammation or other tissue reaction (scar, fibrosis, capsule formation, or other). After removal 
from the tissue, the OxyChip will be recalibrated to confirm that there was no change in the oxygen 
sensitivity during the course of the implantation. The pathologist, the PI, or a co-investigator who is present 
during specimen dissection will note if the OxyChip has been damaged during the extraction. Details in 
standard method 70.x. 
If the OxyChip cannot be identified in the surgical specimen by dissection, the specimen will be subjected 
to MRI, ultrasound, or EPR analysis to visualize the OxyChip, which will facilitate the dissection.  
For the exploratory goals, this tissue will be examined or stored for expression of biomarkers that may be 
associated with hypoxia or tumor growth. 
5.3 Subject Compliance Monitoring 
Patients in Phase 1A will typically have the OxyChip implanted for a short duration (≤ 4 weeks), but may 
remain for up to 52 weeks, and the patient will be seeing the surgeon for surgical planning and post-
operative evaluations, making non-compliance unlikely. Phase 1A patients will be evaluated at least 
monthly prior to the OxyChip removal to check for any adverse events, as per the primary objective. Patients 
in Phase 1B will be receiving daily radiotherapy or a course of chemotherapy and therefore will be seen by 
a physician at least weekly or with each chemotherapy cycle for standard evaluation. At these 
appointments, the PI,  co-investigators or staff protocol members perform safety monitoring by querying the 
patient about his or her local symptoms relating to the OxyChip implantation, and by inspection of the 
implantation site if possible, depending on the patient’s willingness to allow inspection. Evaluation can also 
be performed at  Norris Cotton Cancer Center North by one of the DH radiation or medical oncologists who 
are protocol staff, if the patients elects to receive radiation or chemotherapy at that facility prior to surgery 
(Phase 1B).   
If the patient is unwilling to see the PI or co-investigators during a visit at which toxicity is to be assessed, 
or if the patient is unable to be seen due to logistical considerations, the patient by phone to evaluate 
potential toxicity. All efforts will be made to see the patient in clinic and perform an inspection of the 
implanted site. If the patient is receiving oxygen measurements, the patient will be seen by the EPR team 
at that time, ensuring compliance. It is possible that patients will decline oxygen measurements, but this 
will have a minor impact on the secondary objective (feasibility), and no impact on the primary objective 
(safety). Assessments by non-study physicians as part of standard of care are also an acceptable 
replacement if the patient is not accessible for an in-person evaluation. 

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5.4 Prior and Concomitant Therapy 
• In Phase 1B, radiotherapy or chemotherapy or biologic or endocrine therapy will be delivered. 
• All supportive medications are allowed on this protocol, including antibiotics, if needed. 
• In Phase 1B, chemotherapy will not be given with radiotherapy (concurrently) or consecutively 
prior to surgical explantation of the tumor in this protocol. 
• Angiogenesis inhibitors will not be given with radiotherapy in this protocol. 
• Prior irradiation to the site where the OxyChip will be placed is not allowed. 
5.5 
Packaging 
• There will be no comparative device for the OxyChip. 
• The OxyChips will be sterilized in individual packaging, as described previously. 
• Labels identifying the units as “Investigational Devices: Sterilized OxyChips” will be used on all 
storage containers. 
5.6 Receiving, Storage, Dispensing and Return  
5.6.1 Receipt of study device 
The date of manufacture of the OxyChips by the EPR Center will be kept on an inventory, which will include 
the name of the technician manufacturing the device, and a device log filled out to track the devices. Any 
damaged or unusable study devices found at the time of the implantation procedure will be documented in 
the study files and on the inventory. Devices delivered to the operating room or procedure room will also 
be logged in the Sponsor’s inventory log. 
5.6.2 Storage 
The sterilized OxyChips will be stored in sterile packaging at room temperature (20°C to 23°C [68°F to 
75°F]) and at a relative humidity range not to exceed 70%. All packaging materials will be examined 
regularly for defects and extraneous matter. If wet or damaged packages are observed, they will not be 
released. Access to the location where the OxyChips are stored will be limited (i.e. in a lock box or in a 
room with a lock).The OxyChips will be stored on a closed shelf in a room with a lock to limit access. The 
OxyChips will be stored away from any sprinkler heads, 18 inches away from the floor or ceiling and 2 
inches away from the wall. The OxyChips will be positioned such that they do not get bent, crushed, 
punctured, or compressed.  
5.6.3 Dispensing of study device 
Regular device reconciliation checks will be performed. Information tracked will include which device was 
implanted in a given subject; which device containers were opened to select the specific device to be 
implanted in the subject; whether the subject actually received the assigned device; which devices were 
inadvertently damaged in handling/dispensing. This reconciliation will be logged on the device reconciliation 
form and signed and dated by the study team. After removal of the OxyChip from the pathology specimen, 
the OxyChip will be returned to the sponsor for recalibration and inspection. 
5.6.4 Return or destruction of study device 
At the completion of the study, there will be a final reconciliation of study devices manufactured, devices 
consumed, and devices remaining. This reconciliation will be logged on the device reconciliation form, 
signed and dated. Any discrepancies noted will be investigated, resolved, and documented prior to 
completion of the study. Devices destroyed on site will be documented in the study files. 

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6 Study Procedures 
6.1 Pre-enrollment (Phase 1A, 1B) 
1. Review of any prior imaging studies; this could include an MRI, CT scan or PET/CT scan. 
2. Review of pathology to confirm tumor histology for Phase 1B 
3. The study will be introduced to the patient and the IRB-approved consent form reviewed and 
signed if the patient agrees to participate. No study related procedures should be performed prior 
to informed consent being obtained.  
4. Physical exam performed within 6 weeks of OxyChip implantation procedure. This may be 
performed by non-study physician or physician extender as standard of care or by study 
physician. 
5. Pregnancy test or other standard proof of non-pregnancy for women of reproductive capability at 
the discretion of the physician. 
6. All other eligibility criteria will be reviewed and recorded, e.g., age, no pacemaker. 
a. If platelet blood count and/or absolute Neurophil count (ANC) have not been drawn for 
standard of care within the last months prior to the implantation of the OxyChip, the 
patient will be given the option to have a venipuncture for research purposes only in order 
to confirm eligibility.  
6.2 Placement of the OxyChip (Phase 1A, 1B) 
1. Placement of the OxyChip with a minimally invasive approach (see 5.2.1).  
6.3 Post OxyChip implantation assessment (Phase 1A, 1B) 
1. Phase 1A patients will be evaluated at least monthly prior to OxyChip removal for assessment* with 
respect to any adverse effects for the primary objective.  
2. Phase 1B patients will be evaluated weekly during radiotherapy or prior to each chemotherapy 
administration or follow-up appointment for assessment* of any adverse effects for the primary 
objective.  
* Assessments by non-study physicians or physician extenders as part of standard of care are 
acceptable. If a patient cannot or does not return for an evaluation, the study team will contact the 
patient by phone or email to assess for development of new adverse effects or changes in health 
status. 
 
6.4 Oxygen measurements (Phase 1A, 1B) 
1. The area over the OxyChip is examined for signs of infection or inflammation at each session. 
2. Non-invasive tumor oxygenation measurements are obtained.(see 5.2.2) 
3.  
6.5 Pre-operative assessment (Phase 1A, 1B) 
1. The area over the OxyChip is examined for signs of infection or inflammation. This assessment 
can be performed within two weeks prior to surgery depending on logistical constraints, or by the 
treating physician prior to surgery.  
2. Physical exam is performed within two weeks of surgery. This may be performed by non-study 
physician or physician extender as standard of care or by study physician.  

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6.6 Removal of OxyChip (Phase 1A, 1B) 
1. Surgical resection of the tumor with OxyChip removal in the specimen followed by pathology 
evaluation of specimen. (see 5.2.4 and 5.2.5) 
6.7 Visits after removal of the OxyChip (Phase 1A, 1B) 
1. Patients will be evaluated 1-2 weeks after surgical resection with removal of the OxyChip for 
evaluation of healing. This may be performed by a non-study physician as standard of care or by 
a study physician. If the patient cannot or does not return for post-operative evaluation, the study 
team will contact the patient by phone or email to check for development of new adverse events 
or changes in health status.  
2. While we do not expect any long-term effects following removal of the OxyChip, we will collect 
and examine results from laboratory tests and physical exams obtained ad hoc as a part of 
routine follow-up up to 12 months following implantation.   
7 Statistical Plan 
7.1 Statistical Methods 
This is a first-in-humans pilot study2/Phase I trial designed to (1) test the safety and toxicity of the OxyChip 
and patient tolerance of its presence and to (2) help design a larger confirmatory study. As such, the study 
was sequentially designed into different cohorts, as previously described in section_3.1. The criteria for 
proceeding with each cohort is not based on statistical significance but on the presence and severity of any 
unexpected adverse events and whether they can be attributed to the OxyChip. The sample size was 
selected to be within the range recommended for early phase I trials3,4. 
For purposes of examining the secondary goal, the feasibility of using the OxyChip to assess PO2, we will 
use a qualitative assessment about whether any attempted measurements were successful, and assess 
the time for making measurements. Oxygen measurements will be averaged across visit days (if available) 
per subject for all subjects in Phase 1A and Phase 1B. We will use a paired t-test to detect statistically 
significant acute changes in pO2. To compare time period measurements per visit across patients, we will 
use an ANOVA model to account for individual variation of the baseline pO2. Finally, if the oxygen level 
exhibits a nonlinear pattern we will use a nonlinear fitting technique. To account for substantial variations 
of pO2 across patients, methods of repeated measurements and mixed modeling will be used.  
7.2 Subject Population(s) for Analysis 
The subject populations whose data will be subjected to analysis (both primary and secondary) include all 
evaluable participants in this Phase I trial.  
 
2 US Dept of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health. Center for 
Biologics Evaluation and Research. “Investigational Device Exemptions (IDEs) for Early Feasibility Medical Device Clinical Studies, 
including Certain First in Human (FIH) Studies: Guidance for Industry and Food and Drug Administration Staff”. Document issued 
October 1, 2013. 
http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/HowtoMarketYourDevice/InvestigationalDeviceExemptionIDE/uc
m162453.htm.  
3Browne RH: On the use of a pilot sample for sample size determination. Stat Med. 1995, 14: 1933-1940.  
4Sim J, Lewis M: The size of a pilot study for a clinical trial should be calculated in relation to considerations of precision and 
efficiency. J Clin Epidemiol. 2012, 65: 301-308.  

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8 Safety and Adverse Events 
8.1 Definitions 
8.1.1 Adverse event definitions 
Adverse effect. Any untoward medical occurrence in a clinical study of an investigational device; regardless 
of the causal relationship of the problem with the device or, if applicable, other study treatment or diagnostic 
product(s). 
Associated with the investigational device or, if applicable, other study treatment or diagnostic product(s). 
There is a reasonable possibility that the adverse effect may have been caused by the investigational device 
or, if applicable, the other study treatment or diagnostic product(s). 
Disability. A substantial disruption of a person’s ability to conduct normal life functions. 
Life-threatening adverse effect. Any adverse effect that places the subject, in the view of the investigator-
sponsor, at immediate risk of death from the effect as it occurred (i.e., does not include an adverse effect 
that, had it actually occurred in a more severe form, might have caused death). 
Serious adverse effect. Any adverse effect that results in any of the following outcomes: death, a life-
threatening adverse effect, inpatient hospitalization or prolongation of existing hospitalization, a persistent 
or significant disability/incapacity, or a congenital anomaly/birth defect. 
• 
Hospitalization shall include any initial admission (even if less than 24 hours) to a healthcare 
facility as a result of a precipitating clinical adverse effect; to include transfer within the 
hospital to an intensive care unit. Hospitalization or prolongation of hospitalization in the 
absence of a precipitating, clinical adverse effect (e.g., for a preexisting condition not 
associated with a new adverse effect or with a worsening of the preexisting condition; 
admission for a protocol-specified procedure) is not, in itself, a serious adverse effect.  
 
Unexpected adverse effect. Any adverse effect, the frequency, specificity or severity of which is not 
consistent with the risk information described in the clinical study protocol(s) or elsewhere in the current 
IDE application, as amended. 
8.1.2 Unanticipated adverse device effect (UADE)  
Unanticipated adverse device effect (UADE). 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 IDE 
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. 
8.2 Recording of Adverse Events 
Clinical study subjects will be questioned about adverse effects at study visits. The visits will be documented 
in the clinical records. Adverse effects with suspected causal relationship to study procedures, determined 
by the PI or co-I, will be recorded on study adverse effects forms and summarized in CRFs.  
8.3 Reporting of Adverse Device Effects and Unanticipated Problems 
8.3.1 Investigator reporting: Notifying the study sponsor 
8.3.1.1 
Sponsor contact information for reporting purposes 
Report adverse device effects by phone and facsimile to: Periannan Kuppusamy, Phone: (603) 653-3577; 
Fax (603) 650-1940; Philip Schaner, Phone (603) 650-5000 

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All observed or volunteered adverse effects (serious or non-serious) and abnormal test findings, regardless 
of treatment group, if applicable, with suspected causal relationship to the investigational device or, if 
applicable, other study treatment or diagnostic product(s) will be recorded in the subjects’ case histories. 
For all adverse effects, sufficient information will be pursued and/or obtained so as to permit (i) an adequate 
determination of the outcome of the effect (i.e., whether the effect should be classified as a serious adverse 
effect) and; (ii) an assessment of the casual relationship between the adverse effect and the investigational 
device or, if applicable, the other study treatment or diagnostic product(s).   
Adverse effects or abnormal test findings felt to be associated with the investigational device or, if 
applicable, other study treatment or diagnostic product(s) will be followed until the effect (or its sequelae) 
or the abnormal test finding resolves or stabilizes at a level acceptable to the investigator-sponsor. 
8.3.1.2 
Abnormal test findings 
An abnormal test finding will be classified as an adverse effect if one or more of the following criteria are 
met: 
• 
The test finding is accompanied by clinical symptoms. 
• 
The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant drug or other therapy. (Note: simply 
repeating a test finding, in the absence of any of the other listed criteria, does not constitute an 
adverse effect.) 
• 
The test finding leads to a change in study dosing or exposure or discontinuation of subject 
participation in the clinical study. 
• 
The test finding is considered an adverse effect by the investigator-sponsor. 
 
8.3.1.3 
Causality and severity assessment 
 
The investigator-sponsor will promptly review documented adverse effects and abnormal test findings to 
determine (i) if the abnormal test finding should be classified as an adverse effect; (ii) if there is a reasonable 
possibility that the adverse effect was caused by the investigational device or, if applicable, other study 
treatment or diagnostic product(s); and (ii) if the adverse effect meets the criteria for a serious adverse 
effect. 
If the investigator-sponsor’s final determination of causality is “unknown and of questionable relationship to 
the investigational device or, if applicable, other study treatment or diagnostic product(s)”, the adverse effect 
will be classified as associated with the use of the investigational device or study treatment or diagnostic 
drug product(s) for reporting purposes. If the investigator-sponsor’s final determination of causality is 
“unknown but not related to the investigational device or, if applicable, other study treatment or diagnostic 
product(s)”, this determination and the rationale for the determination will be documented in the respective 
subject’s case history.  
8.3.1.4 
Reporting of adverse effects to the FDA. 
The investigator-sponsor will submit a completed FDA Form 3500A to the FDA’s Center for Devices and 
Radiological Health for any observed or volunteered adverse effect that is determined to be an 
unanticipated adverse device effect. A copy of this completed form will be provided to all participating sub-
investigators.  
The completed FDA Form 3500A will be submitted to the FDA as soon as possible and, in no event, later 
than 10 working days after the investigator-sponsor first receives notice of the adverse effect. 
If the results of the sponsor-investigator’s follow-up evaluation show that an adverse effect that was initially 
determined to not constitute an unanticipated adverse device effect does, in fact, meet the requirements 
for reporting; the investigator-sponsor will submit a completed FDA Form 3500A as soon as possible, but 
in no event later than 10 working days, after the determination was made. 

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For each submitted FDA Form 3500A, the sponsor-investigator will identify all previously submitted reports 
that that addressed a similar adverse effect experience and will provide an analysis of the significance of 
newly reported adverse effect in light of the previous, similar report(s). 
Subsequent to the initial submission of a completed FDA Form 3500A, the investigator-sponsor will submit 
additional information concerning the reported adverse effect as requested by the FDA. 
8.3.2 Reporting of adverse effects to the responsible IRB  
In accordance with applicable policies of the Dartmouth College’s Institutional Review Board (IRB)—the 
Committee for Protection of Human Subjects (CPHS)—the investigator-sponsor will report, to the IRB, any 
observed or volunteered adverse effect that is determined to meet all of the following criteria: (i) associated 
with the investigational device or, if applicable, other study treatment or diagnostic product(s); (ii) a serious 
adverse effect; and (iii) an unexpected adverse effect. Adverse event reports will be submitted to the IRB 
in accordance with the respective IRB procedures.  
Applicable adverse effects will be reported to the IRB as soon as possible and, in no event, later than 10 
working days after an investigator learns of the effect.  
Follow-up information to reported adverse effects will be submitted to the IRB as soon as the relevant 
information is available. If the results of the sponsor-investigator’s follow-up investigation show that an 
adverse effect that was initially determined to not require reporting to the IRB does, in fact, meet the 
requirements for reporting; the investigator-sponsor will report the adverse effect to the IRB as soon as 
possible, but in no event later than 10 working days, after an investigator learns of the effect. 
 
8.3.2.1 
Withdrawal of IRB approval 
The Sponsor shall notify the FDA, all participating IRBs and participating investigators of any withdrawal of 
approval of the study by a reviewing IRB within 5 working days after receipt of the withdrawal of approval. 
8.3.2.2 
FDA reporting process 
Medical Device Reports, whether for anticipated or unanticipated device-related effects, are to be submitted 
on FDA Form 3500A (MEDWATCH Form). The contact information for submitting MDR reports is noted 
below: 
Food and Drug Administration 
Center for Devices and Radiological Health 
Medical Device Reporting 
PO Box 3002 
Rockville, MD 20847-3003 
8.4 Stopping Rules  
The study will be stopped for any grade 3 or higher toxicity. The study will not re-open until the event is 
analyzed and deemed to be unrelated to the OxyChip or oxygen measurements. 
8.5 Medical Monitoring 
It is the responsibility of the PI to oversee the safety of the study at all sites. This safety monitoring will 
include careful assessment and appropriate reporting of adverse effects as noted above, as well as the 
construction and implementation of a site data and safety-monitoring plan (see section 9 Auditing, 
Monitoring and Inspecting). Medical monitoring will include a regular assessment of the number and type 
of serious adverse events. The sponsor and local PIs will meet monthly via conference call to discuss 
progress, safety issues and regulatory processes.  

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9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about all study subjects will be kept confidential and managed according to the requirements 
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Those regulations require a 
signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study? 
• Who will have access to that information and why? 
• Who will use or disclose that information? 
• The rights of a research subject to revoke their authorization for use of their PHI.  
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, retains 
the ability to use all information collected prior to the revocation of subject authorization. For subjects that 
have revoked authorization to collect or use PHI, attempts should be made to obtain permission to collect 
at least vital status (i.e. that the subject is alive) at the end of their scheduled study period. 
9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities in a 
clinical trial necessary for the reconstruction and evaluation of the trial. Source data are contained in source 
documents. Examples of these original documents, and data records include: hospital records, clinical and 
office charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, pharmacy dispensing 
records, recorded data from automated instruments, copies or transcriptions certified after verification as 
being accurate and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, 
subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical departments 
involved in the clinical trial. 
9.3 Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study. All data requested 
on the CRF must be recorded. All missing data must be explained. If a space on the CRF is left blank 
because the procedure was not done or the question was not asked, write “N/D”. If the item is not applicable 
to the individual case, write “N/A”. All entries should be printed legibly in black ink. If any entry error has 
been made, to correct such an error, draw a single straight line through the incorrect entry and enter the 
correct data above it. All such changes must be initialed and dated. DO NOT ERASE OR WHITE OUT 
ERRORS. For clarification of illegible or uncertain entries, print the clarification above the item, then initial 
and date it. 
9.4 Records Retention 
Locally, electronic information will be kept in the secure, password-protected research database. After the 
study is completed, documents containing research information are stored in Dartmouth College Records 
Management off-site storage. Documents are shredded off site after 50 years. 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored by the Data Safety Monitoring and Accrual Committee (DSMAC) of the Norris 
Cotton Cancer Center (NCCC) of Dartmouth-Hitchcock Medical Center. The Clinical Cancer Review 
Committee (CCRC) of NCCC determines the frequency of DSMAC review. The DSMAC meets quarterly to 
review accrual rates and information about studies that have accrued participants, including adverse device 
effects. The DSMAC has the authority to suspend or to recommend termination to the CCRC of all research 

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activities that fall within its jurisdiction. In the event that a study is suspended or terminated, that information 
will be forwarded to the responsible IRB office. 
10.2 On-Site Monitoring 
Clinical research monitoring for regulatory compliance and data integrity will be conducted according to the 
NCI-approved NCCC Data and Safety Monitoring Plan. Internal monitoring is conducted by appropriately 
trained staff of the NCCC Office of Clinical Research and Dartmouth-Hitchcock Medical Center Clinical 
Trials Office who are not involved in the study. This monitoring will include periodic assessment of the 
regulatory compliance, data quality, pharmacy records and study integrity. Study records will be reviewed 
and directly compared to source documents and the conduct of the study will be discussed with the 
investigator. Monitors may request access to all regulatory documents, source documents, CRFs, and other 
study documentation for on-site inspection. Direct access to these documents is guaranteed by the 
investigator, who must provide support at all times for these activities. 
10.3 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the CPHS, government 
regulatory bodies, and NCCC compliance and quality assurance groups of all study related documents (e.g. 
source documents, regulatory documents, data collection instruments, study data, etc.). The investigator 
will ensure the capability for inspections of applicable study-related facilities. Participation as an investigator 
in this study implies acceptance of potential inspection by government regulatory authorities and applicable 
institutional compliance and quality assurance offices. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice (FDA 
Title 21 part 312 and International Conference on Harmonization guidelines), applicable government 
regulations and Institutional research policies and procedures. This protocol and any amendments will be 
submitted to a properly constituted or Institutional Review Board (IRB), in agreement with local legal 
prescriptions, for formal approval of the study conduct. The decision of the IRB concerning the conduct of 
the study will be made in writing to the investigator. All subjects for this study will be provided a consent 
form describing this study and providing sufficient information for subjects to make an informed decision 
about their participation in this study. The written consent of a subject, using the IRB-approved consent 
form, must be obtained before that subject undergoes any study procedure. The consent form must be 
signed by the subject and the investigator-designated research professional obtaining the consent. 
11.1 Funding Source 
This study is being funded as a part of a Program Project Grant (PPG) from the National Cancer Institute 
(P01 CA190193 – Project 2; Direct and Repeated Clinical Measurement of pO2 using OxyChip for 
Enhancing Cancer Therapy (07/01/2015 – 06/30/2020) with Dr. Kuppusamy is the PI. 
11.2 Conflict of Interest 
Because the information to be disclosed differs for the FDA and Dartmouth, the relevant disclosures have 
been filed in a separate supporting document for the CPHS application as well as filed in annual and other 
disclosures required by Dartmouth. The disclosures for the FDA have been signed and filed in a regulatory 
binder by all investigators named in this protocol. 
12 Publication Plan 
As of now, there is no industry sponsor for this study. The OxyChip-based clinical EPR trial has been 
developed by the study investigators at Dartmouth. We plan to publish results from this study in peer-
reviewed journals with all investigators who participate in the study as co-authors. The primary 
investigators, Drs. Kuppusamy and Schaner, will have the responsibility for publication. 

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Neither the complete nor any part of the results of the study carried out under this protocol, nor any of the 
information provided by the sponsor for the purposes of performing the study, will be published or passed 
on to any third party without the consent of the primary investigators. Any investigator involved with this 
study is obligated to provide the primary investigators with complete test results and all data derived from 
the study. 
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Vikram DS, Bratasz A, Ahmad R, Kuppusamy P. A comparative evaluation of EPR and OxyLite 
oximetry using a random sampling of pO(2) in a murine tumor. Radiat Res. 168: 308-315 (2007). 
154. 
Grinberg OY, Grinberg SA, Friedman BJ, Swartz HM. Myocardial oxygen tension and capillary 
density in the isolated perfused rat heart during pharmacological intervention. Advances in experimental 
medicine and biology. 411: 171-181 (1997). 
155. 
Abramovic Z, Hou H, Julijana K, Sentjurc M, Lariviere JP, Swartz HM, Khan N. Modulation of tumor 
hypoxia by topical formulations with vasodilators for enhancing therapy. Advances in experimental medicine 
and biology. 701: 75-82 (2011). 
156. 
Ansiaux R, Baudelet C, Cron GO, Segers J, Dessy C, Martinive P, De Wever J, Verrax J, Wauthier 
V, Beghein N, Gregoire V, Buc Calderon P, Feron O, Gallez B. Botulinum toxin potentiates cancer 
radiotherapy and chemotherapy. Clin Cancer Res. 12: 1276-1283 (2006). 
157. 
Ansiaux R, Baudelet C, Jordan BF, Beghein N, Sonveaux P, De Wever J, Martinive P, Gregoire V, 
Feron O, Gallez B. Thalidomide radiosensitizes tumors through early changes in the tumor 
microenvironment. Clin Cancer Res. 11: 743-750 (2005). 
158. 
Bratasz A, Pandian RP, Ilangovan G, Kuppusamy P. Monitoring oxygenation during the growth of 
a transplanted tumor. Advances in experimental medicine and biology. 578: 375-380 (2006). 
159. 
Crokart N, Danhier F, Daugimont L, Goncalves N, Jordan BF, Gregoire V, Feron O, Bouquet C, 
Gallez B, Preat V. Potentiation of radiotherapy by a localized antiangiogenic gene therapy. Radiother Oncol. 
107: 252-258 (2013). 
160. 
Crokart N, Jordan BF, Baudelet C, Ansiaux R, Sonveaux P, Gregoire V, Beghein N, DeWever J, 
Bouzin C, Feron O, Gallez B. Early reoxygenation in tumors after irradiation: determining factors and 
consequences for radiotherapy regimens using daily multiple fractions. Int J Radiat Oncol Biol Phys. 63: 
901-910 (2005). 

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161. 
Danhier F, Danhier P, Magotteaux N, De Preter G, Ucakar B, Karroum O, Jordan B, Gallez B, Preat 
V. Electron paramagnetic resonance highlights that the oxygen effect contributes to the radiosensitizing 
effect of paclitaxel. PLoS One. 7: e40772 (2012). 
162. 
Doloff JC, Khan N, Ma J, Demidenko E, Swartz HM, Jounaidi Y. Increased tumor oxygenation and 
drug uptake during anti-angiogenic weekly low dose cyclophosphamide enhances the anti-tumor effect of 
weekly tirapazamine. Curr Cancer Drug Targets. 9: 777-788 (2009). 
163. 
Fujii H, Sakata K, Katsumata Y, Sato R, Kinouchi M, Someya M, Masunaga S, Hareyama M, Swartz 
HM, Hirata H. Tissue oxygenation in a murine SCC VII tumor after X-ray irradiation as determined by EPR 
spectroscopy. Radiother Oncol. 86: 354-360 (2008). 
164. 
Gallez B, Jordan BF, Baudelet C, Misson PD. Pharmacological modifications of the partial pressure 
of oxygen in murine tumors: evaluation using in vivo EPR oximetry. Magnetic resonance in medicine : 
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Medicine. 42: 627-630 (1999). 
165. 
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in experimental tumors after a single dose of X-ray irradiation. Cancer Res. 55: 2249-2252 (1995). 
166. 
Hou H, Abramovic Z, Lariviere JP, Sentjurc M, Swartz H, Khan N. Effect of a topical vasodilator on 
tumor hypoxia and tumor oxygen guided radiotherapy using EPR oximetry. Radiat Res. 173: 651-658 
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167. 
Hou H, Khan N, Grinberg OY, Yu H, Grinberg SA, Lu S, Demidenko E, Steffen RP, Swartz HM. 
The effects of Efaproxyn (efaproxiral) on subcutaneous RIF-1 tumor oxygenation and enhancement of 
radiotherapy-mediated inhibition of tumor growth in mice. Radiat Res. 168: 218-225 (2007). 
168. 
Hou H, Khan N, O'Hara JA, Grinberg OY, Dunn JF, Abajian MA, Wilmot CM, Makki M, Demidenko 
E, Lu S, Steffen RP, Swartz HM. Effect of RSR13, an allosteric hemoglobin modifier, on oxygenation in 
murine tumors: an in vivo electron paramagnetic resonance oximetry and bold MRI study. Int J Radiat Oncol 
Biol Phys. 59: 834-843 (2004). 
169. 
Hou H, Lariviere JP, Demidenko E, Gladstone D, Swartz H, Khan N. Repeated tumor pO(2) 
measurements by multi-site EPR oximetry as a prognostic marker for enhanced therapeutic efficacy of 
fractionated radiotherapy. Radiother Oncol. 91: 126-131 (2009). 
170. 
Jordan BF, Beghein N, Aubry M, Gregoire V, Gallez B. Potentiation of radiation-induced regrowth 
delay by isosorbide dinitrate in FSaII murine tumors. Int J Cancer. 103: 138-141 (2003). 
171. 
Jordan BF, Gregoire V, Demeure RJ, Sonveaux P, Feron O, O'Hara J, Vanhulle VP, Delzenne N, 
Gallez B. Insulin increases the sensitivity of tumors to irradiation: involvement of an increase in tumor 
oxygenation mediated by a nitric oxide-dependent decrease of the tumor cells oxygen consumption. Cancer 
Res. 62: 3555-3561 (2002). 
172. 
Jordan BF, Misson P, Demeure R, Baudelet C, Beghein N, Gallez B. Changes in tumor 
oxygenation/perfusion induced by the no donor, isosorbide dinitrate, in comparison with carbogen: 
monitoring by EPR and MRI. Int J Radiat Oncol Biol Phys. 48: 565-570 (2000). 
173. 
Jordan BF, Sonveaux P, Feron O, Gregoire V, Beghein N, Gallez B. Nitric oxide-mediated increase 
in tumor blood flow and oxygenation of tumors implanted in muscles stimulated by electric pulses. Int J 
Radiat Oncol Biol Phys. 55: 1066-1073 (2003). 
174. 
Karroum O, Kengen J, Danhier P, Magat J, Mignion L, Bouzin C, Verrax J, Charette N, Starkel P, 
Calderon PB, Sonveaux P, Feron O, Gregoire V, Gallez B, Jordan BF. Tumor reoxygenation following 
administration of Mitogen-Activated Protein Kinase inhibitors: a rationale for combination with radiation 
therapy. Radiother Oncol. 105: 64-71 (2012). 
175. 
Karroum O, Kengen J, Gregoire V, Gallez B, Jordan BF. Tumor Reoxygenation Following 
Administration of the EGFR Inhibitor, Gefitinib, in Experimental Tumors. Advances in experimental medicine 
and biology. 789: 265-271 (2013). 

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176. 
Khan N, Mupparaju SP, Hou H, Lariviere JP, Demidenko E, Swartz HM, Eastman A. Radiotherapy 
in conjunction with 7-hydroxystaurosporine: a multimodal approach with tumor pO2 as a potential marker 
of therapeutic response. Radiat Res. 172: 592-597 (2009). 
177. 
O'Hara JA, Blumenthal RD, Grinberg OY, Grinberg S, Wilmot C, Goldenberg DM, Swartz HM. 
Tumor pO2 assessments in human xenograft tumors measured by EPR oximetry: location of paramagnetic 
materials. Advances in experimental medicine and biology. 530: 205-214 (2003). 
178. 
O'Hara JA, Goda F, Demidenko E, Swartz HM. Effect on regrowth delay in a murine tumor of 
scheduling split-dose irradiation based on direct pO2 measurements by electron paramagnetic resonance 
oximetry. Radiat Res. 150: 549-556 (1998). 
179. 
O'Hara JA, Goda F, Liu KJ, Bacic G, Hoopes PJ, Swartz HM. The pO2 in a murine tumor after 
irradiation: an in vivo electron paramagnetic resonance oximetry study. Radiat Res. 144: 222-229 (1995). 
180. 
Sersa G, Krzic M, Sentjurc M, Ivanusa T, Beravs K, Cemazar M, Auersperg M, Swartz HM. 
Reduced tumor oxygenation by treatment with vinblastine. Cancer Res. 61: 4266-4271 (2001). 
181. 
Fisher E, Khan M, Steiner R, Kuppusamy P. Challenges to intestinal pO measurement using EPR. 
Advances in experimental medicine and biology. 701: 37-44 (2011). 
182. 
Matsumoto A, Matsumoto S, Sowers AL, Koscielniak JW, Trigg NJ, Kuppusamy P, Mitchell JB, 
Subramanian S, Krishna MC, Matsumoto K. Absolute oxygen tension (pO(2)) in murine fatty and muscle 
tissue as determined by EPR. Magnetic resonance in medicine : official journal of the Society of Magnetic 
Resonance in Medicine / Society of Magnetic Resonance in Medicine. 54: 1530-1535 (2005). 
183. 
Jordan BF, Kimpalou JZ, Beghein N, Dessy C, Feron O, Gallez B. Contribution of oxygenation to 
BOLD contrast in exercising muscle. Magnetic resonance in medicine : official journal of the Society of 
Magnetic Resonance in Medicine / Society of Magnetic Resonance in Medicine. 52: 391-396 (2004). 
184. 
Towner RA, Sturgeon SA, Khan N, Hou H, Swartz HM. In vivo assessment of nodularin-induced 
hepatotoxicity in the rat using magnetic resonance techniques (MRI, MRS and EPR oximetry). Chem Biol 
Interact. 139: 231-250 (2002). 
185. 
James PE, Bacic G, Grinberg OY, Goda F, Dunn JF, Jackson SK, Swartz HM. Endotoxin-induced 
changes in intrarenal pO2, measured by in vivo electron paramagnetic resonance oximetry and magnetic 
resonance imaging. Free radical biology & medicine. 21: 25-34 (1996). 
186. 
Krzic M, Sentjurc M, Kristl J. Improved skin oxygenation after benzyl nicotinate application in 
different carriers as measured by EPR oximetry in vivo. J Control Release. 70: 203-211 (2001). 
187. 
Biswas S, Roy S, Banerjee J, Hussain SR, Khanna S, Meenakshisundaram G, Kuppusamy P, 
Friedman A, Sen CK. Hypoxia inducible microRNA 210 attenuates keratinocyte proliferation and impairs 
closure in a murine model of ischemic wounds. Proceedings of the National Academy of Sciences of the 
United States of America. 107: 6976-6981 (2010). 
188. 
Fries RB, Wallace WA, Roy S, Kuppusamy P, Bergdall V, Gordillo GM, Melvin WS, Sen CK. Dermal 
excisional wound healing in pigs following treatment with topically applied pure oxygen. Mutation 
Research/Fundamental and Molecular Mechanisms of Mutagenesis. 579: 172-181 (2005). 
189. 
Lu C, Rollins M, Hou H, Swartz HM, Hopf H, Miclau T, Marcucio RS. Tibial fracture decreases 
oxygen levels at the site of injury. Iowa Orthop J. 28: 14-21 (2008). 
190. 
Lu C, Saless N, Hu D, Wang X, Xing Z, Hou H, Williams B, Swartz HM, Colnot C, Miclau T, Marcucio 
RS. Mechanical stability affects angiogenesis during early fracture healing. J Orthop Trauma. 25: 494-499 
(2011). 
191. 
Eubank TD, Roberts RD, Khan M, Curry JM, Nuovo GJ, Kuppusamy P, Marsh CB. Granulocyte 
macrophage colony-stimulating factor inhibits breast cancer growth and metastasis by invoking an anti-
angiogenic program in tumor-educated macrophages. Cancer Res. 69: 2133-2140 (2009). 
192. 
Khan M, Meduru S, Gogna R, Madan E, Citro L, Kuppusamy ML, Sayyid M, Mostafa M, Hamlin 
RL, Kuppusamy P. Oxygen cycling in conjunction with stem cell transplantation induces NOS3 expression 
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Kwiatkowski P, Kuppusamy P. Labeling of skeletal myoblasts with a novel oxygen-sensing spin probe for 
noninvasive monitoring of in situ oxygenation and cell therapy in heart. Am J Physiol Heart Circ Physiol. 
292: H1254-1261 (2007). 
194. 
Wisel S, Khan M, Kuppusamy ML, Mohan IK, Chacko SM, Rivera BK, Sun BC, Hideg K, 
Kuppusamy P. Pharmacological preconditioning of mesenchymal stem cells with trimetazidine (1-[2,3,4-
trimethoxybenzyl]piperazine) protects hypoxic cells against oxidative stress and enhances recovery of 
myocardial function in infarcted heart through Bcl-2 expression. J Pharmacol Exp Ther. 329: 543-550 
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211. Fawaz ZA, Yassa M, Nguyen DH, Vavassis P. Fiducial marker implantation in prostate cancer radiation 
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 Attachments (as submitted to the FDA in Aug 6, 2014) 
14 This section should contain all pertinent documents associated with 
the management of the study.  
 
IDE Checklist 
1. Description of methods, facilities and controls used for the manufacture of the device 
2. A sample Investigation Agreement Form 
3. Certification of Investigator agreement 
4. List of Institutional IRB chairpersons 
5. Approval letter from CCRC (Pre-IRB review) 
6. Participant informed consent form 
7. Description of EPR device & measurement protocol 
8. Publications related to EPR oximetry & OxyChip 
9. Report of ISO 10993-12: 2012 Chemical characterization analysis