Use of Non-invasive Optical Analysis in Neurosurgery - A Pilot Study
Phase: NA
Conditions: Brain Tumour, Glioma, Meningioma, Brain Metastases, Schwannoma
Sponsor: Imperial College London

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Use of non-invasive optical analysis in Neurosurgery – A pilot 
study 
Study Protocol 30/12/2019, Version 2.0 
 
MAIN SPONSOR: Imperial College London 
FUNDERS: Brain Tumour Research 
STUDY COORDINATION CENTRE: Charing Cross Hospital – Imperial College NHS Trust 
IRAS Project ID: 258210 
REC reference:  
 
 
Chief Investigator: Mr Kevin O’Neill, Dan Elson 
 
Co-investigators:  
Mr Giulio Anichini – Study coordinator, also responsible for patients’ recruitment, intra-
operative data acquisition, data analysis, writing and submission of the research.  
Mr Neekhil Patel – Responsible for patients’ recruitment, intra-operative data acquisition, and 
data analysis 
Mr David Peterson - Responsible for patients’ recruitment and intra-operative data acquisition 

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Professor Dan Elson, Dr Iani Gayo, Dr Ioannis Gkouzionis, Dr Maria Leiloglou, Dr Vadzim Chalau, 
Dr Elizabeth Noble – Responsible for data processing and analysis  
Mr Babar Vaqas – Responsible for data analysis, writing and submission review 
 
Statistician: members of ICL / Hamlyn Center – to be defined 
Study Coordination Centre 
For general queries, supply of study documentation, and collection of data, please contact: 
Study Coordinator: Mr Giulio Anichini 
Address: Charing Cross Hospital, 3rd Floor South Corridor, Fulham Palace Rd, 
Hammersmith, London W6 8RF 
Registration: GMC 7422941 
Tel: 020 3311 7678 
E-mail: g.anichini@imperial.ac.uk, g.anichini@nhs.net  
 
CLINICAL QUERIES 
Clinical queries should be directed to Mr Giulio Anichini, who will direct the query to the 
appropriate person 
 
 
 

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SPONSOR 
Imperial College of London is the main research Sponsor for this study.  For further information 
regarding the sponsorship conditions, please contact the Head of Regulatory Compliance at: 
Joint Research Compliance Office 
Imperial College London and Imperial College Healthcare NHS Trust 
Room 215, Level 2, Medical School Building 
Norfolk Place 
London, W2 1PG 
Tel: 0207 594 9459/ 0207 594 1862 
http://www3.imperial.ac.uk/clinicalresearchgovernanceoffice  
 
Funder: Brain Tumour Research 
 
This protocol describes the “Use of non-invasive optical analysis in Neurosurgery – a 
Pilot study” and provides information about procedures for entering participants.  Every care 
was taken in its drafting, but corrections or amendments may be necessary. These will be 
circulated to investigators in the study.  Problems relating to this study should be referred, in 
the first instance, to the Chief Investigator. The study will adhere to GCP and the UK Policy 
Frame Work for Health and Social Care Research. 
 
This study will adhere to the principles outlined in the UK Policy Frame Work for Health 
and Social Care Research. It will be conducted in compliance with the protocol, the Data 
Protection Act and other regulatory requirements as appropriate.  
 

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INDEX 
 
1. INTRODUCTION 
 
 
 
 
 
 
 
 
5 
1.1. BACKGROUND 
 
 
 
 
 
 
 
 
5 
1.2. RATIONALE FOR THE CURRENT STUDY 
 
 
 
 
6 
2. STUDY OBJECTIVES 
 
 
 
 
 
 
 
7 
3. STUDY DESIGN 
 
 
 
 
 
 
 
 
7 
3.1. STUDY OUTCOME MEASURES 
 
 
 
 
 
 
7 
4. PARTICIPANT ENTRY 
 
 
 
 
 
 
 
8 
4.1. MATERIALS AND METHODS 
 
 
 
 
 
 
9 
4.2. CONFIDENTIALITY  
 
 
 
 
 
 
 
11 
4.3. INCLUSION CRITERIA 
 
 
 
 
 
 
 
12 
4.4. EXCLUSION CRITERIA 
 
 
 
 
 
 
 
13 
5. ADVERSE EVENTS  
 
 
 
 
 
 
 
13 
5.1. NON-SERIOUS AEs 
 
 
 
 
 
 
 
 
13 
5.2. SERIOUS AEs  
 
 
 
 
 
 
 
 
14 
6. STATISTICS AND DATA ANALYSIS  
 
 
 
 
15 
6.1. FIRST AIM 
 
 
 
 
 
 
 
 
 
15 
6.2. SECOND AIM  
 
 
 
 
 
 
 
 
16 
6.3. THIRD AIM 
 
 
 
 
 
 
 
 
 
17 
7. FURTHER DEVELOPMENT  
 
 
 
 
 
 
17 
8. REGULATORY ISSUES  
 
 
 
 
 
 
18 
8.1. ETHICS APPROVAL  
 
 
 
 
 
 
 
18 
8.2. CONSENT 
 
 
 
 
 
 
 
 
 
18 
8.3. CONFIDENTIALITY  
 
 
 
 
 
 
 
19 
8.4. INDEMNITY  
 
 
 
 
 
 
 
 
 
20 
8.5. SPONSOR  
 
 
 
 
 
 
 
 
 
20 
8.6. FUNDING  
 
 
 
 
 
 
 
 
 
21 
8.7. AUDITS  
 
 
 
 
 
 
 
 
 
21 
9. STUDY MANAGEMENT   
 
 
 
 
 
 
21 
10. PUBLICATION POLICY  
 
 
 
 
 
 
21 
11. GANTT CHART  
 
 
 
 
 
 
 
 
22 
12. REFERENCES 
 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
 
 
 
 

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1. INTRODUCTION 
1.1. BACKGROUND 
 
Surgical resection of brain tumours is challenging from both an anatomical and functional 
perspective. The goal of the neurosurgeons is to remove as much tumour tissue as possible, 
while preserving surrounding normal brain. This often remains a utopic goal. Brain tissue 
around the tumour is in fact quite rarely completely normal, as it is invaded by tumour cells, 
and the tumour margins are not clearly defined, but fade into normal tissue. In order to 
overcome this problem, current trend in neurosurgery is to push the margins of resection 
beyond the obvious tumour boundaries and try to resect also those areas of the brain that the 
surgeon suspects have been invaded by tumour cells. However, this choice also poses some 
problematic challenges. The main obstacle to a generous resection is the presence of the so-
called “eloquent areas” of the brain, that is, regions of the brain not amenable to be resected 
otherwise the patient will unequivocally develop a permanent disability (e.g. paralysis / mutism 
/ visual impairment / etc.). Therefore, the concept of “functional margins” of resection has been 
popularized in neurosurgery: tumour resection is carried out up to the point where an eloquent 
area of the brain is reached. The resection is stopped at that point in order to spare that specific 
functional area.  
 
Identifying and preserving eloquent brain areas is possible thanks to technological 
advancements in the field of neurophysiology. Neurophysiological monitoring techniques 
include a series of continuous tests performed during surgery, either with the patient fully 
sedated, or conscious during surgery (in this case the procedure is performed under local 
anaesthesia). Although feasible, this solution is not overly practical nor completely reliable. 
Experienced and extensively trained anaesthetic, surgical and neurophysiological teams are an 
indispensable requirement. Even so, false positives or false negatives can occur, reducing the 
extent of surgical resection in the first case, or increasing the likelihood of a post-operative 
impairment in the second.  
 
 

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1.2. RATIONALE FOR THE CURRENT STUDY 
 
With the present research project, we are aiming to test a technology that could 
potentially improve the extent of resection of brain tumours. The main goal is to develop an 
instrument capable of better identifying differences between brain tumours margins and normal 
brain tissue, and differences between functionally active areas of the brain (“eloquent areas”) 
and non-eloquent areas, thus allowing the surgeon sparing them while performing an 
aggressive surgical resection on the tumour tissue. 
From a theoretical standpoint, one way to distinguish tumour tissue from the 
surrounding brain is to study the micro-architecture of blood vessels, the pattern of blood 
perfusion, and the levels of oxygenation / deoxygenation. A subset of radiological and 
molecular studies has focused on this point [1-2]. Moreover, functional Magnetic Resonance 
Imaging (fMRI) is based on a similar concept [3], as it analyses the differences in 
oxyhaemoglobin and deoxyhaemoglobin in specific brain areas during the execution of a task. 
The intra-operative analysis of differences in blood perfusion and micro-architecture is a 
relatively poorly explored field so far. Most of the studies are pre-clinical and have been 
performed on animals or animal models [4-7], and are mostly focused on different body 
districts.  
The hardware behind multi-spectral analysis consists in a dedicated camera analysing 
the reflected light from a tissue, and dividing it into smaller wavelengths. Specific tissue tends 
to reflect different wavelengths; therefore, the spectral analysis can potentially detect subtle 
differences in tissue composition. Multispectral analysis has already been used in lung, colon, 
skin, and head and neck surgery in pre-clinical and clinical studies [7-13]. Preliminary results 
show different blood volumes and oxygenation rates in different tissues, meaning that the 
technology can be used to study discrepancies in appearance of tumour tissue as opposite to 
normal mucosa [7][9] [11-12]. The main advantages of this technology are that: it is non-
invasive, costs are low, the machinery is not particularly bulky thus the hindrance in theatre is 
limited, and the acquisition time is short. 
 
 

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2. STUDY OBJECTIVES 
 
The present study aims to investigate the potential application of multispectral analysis, 
hyperspectral imaging, and fluorescence during neurosurgical procedures, specifically during 
brain tumour resection. The research procedure consists of images acquisition and data 
processing, with virtually no additional invasive procedures to be performed on patients. 
Study aims: 
1) detect structural differences between brain tumour tissue and surrounding brain; 
2) detect structural differences between eloquent/functional and non-eloquent/non-functional 
brain areas; 
3) test wheter the combination of multispectral/hyperspectral analysis and fluorescence could 
provide additional information about the structural differences of brain tumours VS normal 
brain tissue.  
 
3. STUDY DESIGN  
Type of study: pilot study - prospective cohort study 
Estimated total study duration: 3 years 
Planned study sites: Imperial College of London and Imperial College NHS Trust 
Sample size: 50 patients 
 
3.1. STUDY OUTCOME MEASURES 
Primary outcome measures:  
 
The primary outcome measure will be the analysis of spectroscopic signal reading of: 

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• brain tissue and tumour tissue; 
• functional brain areas and non-functional brain areas. 
 
In order to analyse differences between brain tissue and tumour tissue, the signals 
collected will be correlated both to the visual signal seen on normal operative field and the 
signal seen on the peri-operative imaging (MRI scan). 
 
In order to analyse differences between eloquent and non-eloquent brain areas, the signal 
collected will be correlated with the neuro-physiological intra-operative findings, in every case 
there is an indication to do so, and with the expected location of the eloquent areas on the peri-
operative images.  
 Secondary outcome measures: 
 
The secondary outcome measure will be the analysis of spectroscopic signal reading of 
surgical field as seen at its baseline and under fluorescence-specific light.  
 
 
4. PARTICIPANT ENTRY 
 
The present project consists of a pilot observational study on patients diagnosed with 
brain tumours candidate for a neurosurgical operation.  
 
Patients will be recruited following the inclusion criteria: any patient with a diagnosis of 
brain tumour, age ranging from 18 with no upper limit, who will agree to the operation and to 
take part of the present study, will be enrolled.  
The present study will include: 
• In vivo microscopic and/or endoscopic multispectral/hyperspectral analysis; 
• In vivo microscopic and/or endoscopic fluorescence (using either infrared light - IR - or 
ultraviolet light, depending on the clinical indication of the specific case); 

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• 
In 
vivo 
microscopic 
and/or 
endoscopic 
fluorescence 
combined 
with 
multispectral/hyperspectral analysis. 
 
Enrolment will proceed for 3 years, with the possibility of stopping the research at an 
earlier date if a sufficient amount of data is collected for a reliable statistical analysis. From a 
practical point of view, participation in the study will only imply that some images will be 
acquired during surgery and processed at a later stage. The study won't impact on patients' care 
at any stage, nor will produce results that will be relevant for future medical records of patients 
enrolled. Patients will be approached about this study at the time of their first neuro-oncology 
clinic consultation – this might not necessarily be the clinic where the diagnosis will be given 
for the first time, as these patients are often referred from other centres where the diagnosis has 
already been communicated. A member of the research team who is also involved in direct care 
will be present at the time of the consultation and will explain in details what are the purposes 
and the methods of the present study. The patient will be given a PIS at this point.  
 
Consent will be taken by a member of the research team. Consent will be sought at 
preoperative assessment or in a private room in the admissions lounge, in the clinic, or in the 
hospital ward, in CXH. Consultation length can vary depending on the complexity of the 
clinical procedure planned. Surgery is usually scheduled at least a few days after the clinic 
consultation, in most cases a few weeks after, in a minority of cases some months after. If the 
patient agrees to take part in the study, the patient will sign the consent form for research within 
the day before the surgery, thus allowing sufficient time for questions and autonomous research 
about the topic.  
 
4.1. MATERIALS AND METHODS  
 
A Liquid Crystal Tunable Filter (LCTF) camera will be used for the purpose of the 
present study. The camera has been assembled by Imperial College of London and will be 
connected to the operative microscope and endoscope. The whole system (microscope + 
attached camera) will be draped using sterile drapes as per standard procedure in neurosurgery.  
The camera itself is in turn connected also to a dedicated computer with dedicated software for 

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images acquisition. The instrument has been previously used in other studies performed by 
some of the research team members [12-13]. 
 
Patients who have agreed to take part in the present study will be admitted in Charing 
Cross Hospital, Neurosurgery Department, 11th floor, south corridor. The day before the 
surgery, as standard NHS practice for these procedures. Except for further discussion on the 
details of the study and signing the consent form for research, there won't be any additional test 
required for the patient other than those for standard NHS clinical care. The day of the surgery, 
the procedure will be carried out as expected per clinical indication. Surgery will be performed 
in Charing Cross Hospital, 14th floor, Theatre area. The caring surgeons will also be members 
of the research team.   
 
The patient will be anesthetized and be placed on the surgical table. WHO checklist will 
be performed and the operating procedure will be carried out as standard NHS practice.  During 
surgery, the operating surgeon will be using standard NHS neurosurgical equipment such as an 
endoscope and/or a microscope. From the surgeon’s perspective, this equipment is operated in 
exactly the same way as with any other procedure.  The only technical modification would be 
that either the microscope or the endoscope in use will be connected to the system of camera 
and filters for multispectral/hyperspectral analysis.  Use of this imaging acquisition technique 
will not change standard operative practice, nor will it interfere with the principles of 
neurological surgery. During each surgical intervention, tissue-specific spectral data will be 
collected at specific stages - mostly once the brain surface is exposed and at the end of the 
resection on the surgical cavity. It is important that there is a method of comparing the spectral 
data generated by multispectral imaging to the nature of the tissue being dissected. In order to 
do this, we plan to visually record the operation in order to sync visual data with the spectral 
data obtained at the same moment in time. The video recording will not be patient identifiable 
and will be viewed only by members of the research team working on this project (see below). 
The use of video recording equipment will be included in the patient information sheet given 
to all patients prior to gaining consent.  
 
Pseudo-anonymized clinical data will also be collected on College computers to be 
matched with intra-operative data. Specifically, the researchers will collect: 

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• clinical data such as diagnosis, age, sex, clinical status, medical background – this data 
collection will be performed to ensure that our population is homogeneous according to 
common statistical parametric tests; moreover, some clinical information (such as the 
neurological baseline of the patient) will be crucial in order to quantify exactly the degree 
of reliability of the multispectral signal for eloquent areas detection; 
• radiological and histological data – this data collection will be performed for the purpose 
of the correlation between the multispectral signal and the radiological and/or 
histological findings; 
 
 Surgery will be conducted following standard procedures, already validated in clinical 
practice. The surgeons performing the procedures will be Mr Kevin O’Neill (CI), Mr Giulio 
Anichini (PhD student and clinical fellow), Mr David Peterson (Consultant Neurosurgeon), 
and Mr Neekhil Patel (Neurosurgery Trainee and Clinical Lecturer). Surgeons will work in 
teams, each team with no more than two surgeons. Prof Daniel Elson and one of his 
collaborators will be present in theatre to facilitate images acquisition. For each researcher not 
normally involved in clinical practice, research passport will be provided. Intra-operative 
imaging data and spectra will be collected during tumour resection, but the analysis on the 
spectra will be performed on a different time and setting, in order not to excessively prolong 
the surgical procedure.  
 
Researchers will collect spectral data up until the statistical model used for multivariate 
analysis does not longer improve the degree of accuracy (see Section 6 - statistical analysis).   
 
4.2. CONFIDENTIALITY 
 
Each patient will be given a specific protocol number – ID log. Anonymous video 
recording and/or images acquisition will be carried out by the team members in order to sync 
spectral data collected with the surgical procedure and will be linked with the ID log. These 
data will be hosted in secured Imperial College Computers, and College Server, accessible only 
by members of the research team, and under password protection.  

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Regarding clinical data, these will be stored on NHS Trust Encrypted computers in a 
semi-anonymized form and transferred on College Computers in a pseudo-anonymized form if 
needed for study purposes. NHS computers follow NHS Trust confidentiality policy and 
comply with the Data Protection Act. Semi-anonymization means that these data will include 
NHS number, Hospital Number, age, protocol number. If for study purposes, the team will 
need to transfer these data to College Computers, pseudo-anonymization will be performed 
prior to transfer clinical data to the College computers. Pseudo-anonymization means that these 
data will NOT include any identifiable information, including NHS number and hospital 
number, but only the protocol number – ID log. 
 
PID (Personal Identifiable Data) will be stored for 10 years as per College retention 
policy.  
 
Signed consent forms will be archived inside the patients' medical records and will be 
available for any audit and research quality control activities. Patients will be given a copy of 
the signed consent form. A Trial Master File (TMF) containing hard copies of the consent 
forms will be kept in the Neurosurgery Department in Charing Cross Hospital 3S (offices). 
Entry into these facilities is restricted and controlled in hours. A specific code is required to 
access the facility out of hours, and only members of staff have access. No other copies will be 
done or retained.   
 
4.3. INCLUSION CRITERIA: 
• 
Above the age of 18, no upper age limit 
• 
Sex: male or female 
• 
Candidates for surgery due to a confirmed clinical and radiological diagnosis of cranial 
intrinsic or extrinsic tumour – any histological diagnosis confirming neuro-oncological disease, 
including primary and secondary disease 
• 
Agreed to take part to the present research protocol and signed proper informed consent 
form 
 

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4.4. EXCLUSION CRITERIA: 
• 
Suspected differential diagnosis of pathological condition affecting central nervous 
system other than neuro-oncological disease - including demyelinating diseases, infections, 
brain traumas / haematomas, vascular or auto-immune diseases 
• 
Patients not capable to give consent – not in condition of understanding, processing and 
retaining information 
 
 
5. ADVERSE EVENTS 
 
As per the definition of adverse event (“Adverse Events (AEs) are any unfavourable and 
unintended signs, including abnormal laboratory results, symptoms or a disease associated with 
treatment.” 
- 
https://www.nbt.nhs.uk/research-innovation/running-your-study/safety-
reporting/classification-adverse-events), we do not expect for this technology to cause any 
adverse event whatsoever. The light sources are the same used in every standard neurosurgical 
procedure. The only real difference that the acquisition will make is to prolong time of the 
surgery by approximatively 5 minutes for each acquisition at the most. 
 
The worst-case scenario will be that of technical failure of the acquisition, with no 
possibility of data storage or analysis. This will not impact in any form on patient’s treatment 
and outcome. In the very unlikely occurrence of a SAE, standard procedures will be followed, 
as described below.  
 
5.1. NON SERIOUS AEs 
All such events, whether expected or not, will be recorded and notified by the investigators 
to the CI. 
 

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5.2. SERIOUS AEs 
An SAE form should be completed and faxed to the Chief Investigator within 24 hours. 
However, relapse and death due to the diagnosis (brain tumour and/or vascular anomaly), and 
hospitalisations for elective treatment of a pre-existing condition do not need reporting as SAEs.  
All SAEs should be reported to the REC where in the opinion of the Chief Investigator, the 
event was:  
• 
‘related’, ie resulted from the administration of any of the research procedures; and  
• 
‘unexpected’, ie an event that is not listed in the protocol as an expected occurrence  
Reports of related and unexpected SAEs should be submitted within 15 days of the Chief 
Investigator becoming aware of the event, using the NRES SAE form for non-IMP studies. The 
Chief Investigator must also notify the Sponsor of all SAEs.  
Local investigators should report any SAEs as required by their Local Research Ethics 
Committee, Sponsor and/or Research & Development Office.  
Contact details for reporting SAEs  
jrco@imperial.ac.uk  
CI email (kevin.oneill@nhs.net) Fax: xxx. Please send SAE forms to: Mr Kevin O’Neill and /or Mr 
Giulio Anichini Tel: 020 33135503 
 (Mon to Fri 09.00 – 17.00)  
 
 
6. STATISTICS AND DATA ANALYSIS 

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Parametric tests will be performed on the patients’ clinical data to make sure that the 
sample is homogeneous and consistent with the other literature series reporting similar 
diseases.  
 
6.1. FIRST AIM  
Detect structural differences between brain tumour tissue and surrounding brain. 
 
The Regions Of Interest (ROI) for multispectral/hyperspectral acquisition will be 
delineated on both peri-operative images (MRI scan) and intra-operative images as 
extrapolated from the intra-operative videos. We will focus our analysis on three main regions:  
• normal brain tissue - brain tissue not infiltrated by tumour or edema, nor grossly 
pathological on pre-operative images or intra-operative images;  
• suspected infiltrated brain tissue – tissue surrounding the tumour where there is strong 
radiological and clinical suspicion of infiltrative disease or edema; 
• tumour tissue – margins and core of the tumour on pre-operative images and intra-
operative findings.  
 
The signal in one region of the tumour will be compared to a neighbouring ‘healthy’ 
region. The signal itself will come from a processed set of images of the brain, where we will 
fit the data using one of our established models to extract an indication of tissue oxygenation 
(as a %) on a per-pixel basis.  
 
The comparison between the set of readings obtained from normal brain will be 
performed using Principal Component Analysis (PCA) and Linear Discriminant Analysis 
(LDA) or more advanced techniques including, for example, machine learning. Statistics will 
be collected on accuracy, sensitivity, specificity, ROC analysis. 
 
We will also need to take pictures and/or videos of the surgical field in order to correlate 
the expected anatomical location of the tumour and infiltrated areas with the intra-operative 
finding. The surgical field is limited to the area under the microscope or endoscope 

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magnification, therefore no identifiable pictures or videos will be taken at any point during the 
study.  
 
6.2. SECOND AIM 
Detect differences between eloquent/functional and non-eloquent/non-functional brain 
areas. 
 
The Regions Of Interest (ROI) for multispectral/hyperspectral acquisition will be 
delineated on both peri-operative images (MRI scan) and intra-operative images as 
extrapolated from the intra-operative videos. For the purpose of this subsection, we will focus 
our analysis on the comparison between a supposed eloquent area and its surrounding brain 
tissue. In order to achieve this, we will consider to perform multispectral/hyperspectral 
acquisition on patients undergoing surgery with neurophysiology monitoring - Motor Evoked 
Potentials (MEP), SomatoSensory Evoked Potentials (SSEP), Visual Evoked Potentials (VEP), 
Auditory Evoked Potentials (AEP) - , and/or in patients undergoing awake surgery. 
 
The presence of eloquent brain tissue will be confirmed both anatomically by identifying 
it on peri-operative and intra-operative assessment, and through neuromonitoring stimulation 
and/or the execution of a single task during awake surgery, as standard clinical practice in 
surgery for brain tumours in eloquent areas. From this point of view, clinical correlation with 
the patient’s pre-operative neurological status is crucial in order to consider potential variations 
in the strength of the intra-operative signal and activation pattern of the analysed eloquent areas 
– example: a patient with a pre-operative limb weakness is expected to show a different level 
of activation and therefore might show a different spectroscopic signal compared to a patient 
with normal motor power. We will also need to take pictures and/or videos of the surgery in 
order to correlate the expected anatomical location of an eloquent area with the intra-operative 
finding. The surgical field is limited to the area under the microscope or endoscope 
magnification, therefore no identifiable pictures or videos will be taken at any point during the 
study. 
 
Same tests as section 6.1 will be run to statistically validate the data.  

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6.3. THIRD AIM  
 
Test whether the combination of multispectral/hyperspectral analysis and fluorescence 
could provide useful new insight into the detection of different perfusion patterns of brain 
tumours VS normal brain tissue 
 
Multispectral/hyperspectral imaging will be tested to check whether it can increase the 
distinction of the fluorophore signal compared with the background. Dedicated statistical 
software will be used for this analysis. 
 
Each image set will be analysed separately because there will be variability between 
patients and we will not be able to fully account for this with the limited number of datasets 
that we are going to record (a well-known problem with many biophotonics/optical 
techniques). This will all be done offline after the surgery is complete, with a primary aim is to 
observe whether the technique is capable of detecting changes in the tissue. 
 
We will collect spectral data up until the statistical model used for multivariate analysis 
does not longer improve the degree of accuracy. We will aim to recruit approximately 50 
patients with diagnosis of neuro-oncological disease. Each patient will have an average 
acquisition of 6 datasets. As each dataset will correspond to an image, this will be divided into 
many reading regions (from 10 to 20) for a total of approximatively 60 measurements per 
patient. Based on this estimation, we approximate that 50 patients will provide a spectral 
database of 3.000 spectra, which we calculate is adequate for diagnostic validation purposes 
[14]. 
 
Same tests as section 6.1 will be run to statistically validate the data.  
 
7. FURTHER DEVELOPMENT 
This technology is completely novel, and in our estimation, it has the potential of 
changing the neuro-oncological surgery practice. Our hypothesis is that it could effectively 

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detect differences between brain and tumour tissues. Therefore, the present study could 
ultimately become a benchmark for the development of a new tool to guide the surgeon during 
brain tumours resection. It would also provide the community with more knowledge and 
understanding of the functional anatomy of the brain. More specifically, it could increase our 
knowledge of the vascular re-arrangement, structure, and oxygenation of brain tumours, as well 
as additional knowledge about perfusion and oxygen extraction in the brain between eloquent 
and non-eloquent areas – thus representing an intra-operative equivalent of a functional MRI, 
but without the same intra-operative hindrance and costs.  
 
 
8. REGULATORY ISSUES  
8.1. ETHICS APPROVAL 
The Study Coordination Centre has obtained approval from the Research Ethics Committee 
(REC) and Health Regulator Authority (HRA). The study must also receive confirmation of 
capacity and capability from each participating NHS Trust before accepting participants into the 
study or any research activity is carried out. The study will be conducted in accordance with the 
recommendations for physicians involved in research on human subjects adopted by the 18th 
World Medical Assembly, Helsinki 1964 and later revisions. 
 
8.2. CONSENT  
Consent to enter the study must be sought from each participant only after a full explanation 
has been given, an information leaflet offered and time allowed for consideration.  Signed 
participant consent should be obtained.  The right of the participant to refuse to participate without 
giving reasons must be respected.  After the participant has entered the study the clinician remains 
free to give alternative treatment to that specified in the protocol at any stage if he/she feels it is in 
the participant’s best interest, but the reasons for doing so should be recorded.  In these cases the 

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participants remain within the study for the purposes of data analysis.  All participants are free to 
withdraw at any time from the protocol treatment without giving reasons and without prejudicing 
further treatment. 
 
8.3. CONFIDENTIALITY 
The Chief Investigator will preserve the confidentiality of participants taking part in the study 
and is registered under the Data Protection Act. 
There are two sets of data the researchers will collect: 
1) Intra-operative images / videos and spectroscopic data; 
2) Clinical data: diagnosis, clinical status, medical background, radiological, 
histopathological data, treatment data. 
Regarding intraoperative multispectral data collection, these will be stored mostly on College 
Computers, and recording devices. Anonymous video recording and/or images acquisition will be 
carried out by the clinicians in order to sync spectral data collected with the surgical procedure. Each 
patient will be given a specific protocol number – Log ID. These data will be in pseudo-anonymized 
form when transferred to College Computers, and the images and videos will be coded using the 
specific protocol number / log ID previously assigned.  
Regarding clinical data, these will be stored on NHS Trust Encrypted computers in a semi-
anonymized form, and transferred on College Computers in a pseudo-anonymized form. NHS 
computers follow NHS Trust and Imperial College confidentiality policy. Semi-anonymization 
means that these data will include NHS number, Hospital Number, age, protocol number. No 
additional identifiable personal data – such as telephone numbers, address, name, and surname – will 
be stored, except for those on the copies of the consent forms for the Trial Master Files (TMF). These 
will be stored in a safe and restricted environment in CXH 3S (officies).  Pseudo-anonymization will 
be performed prior to transfer clinical data to the College computers. Pseudo-anonymization means 
that these data will NOT include any identifiable information, including NHS number and hospital 
number. Only the protocol number / log ID will be included in the data stored on College Computers. 

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The following clinical data will be stored on College Computers: diagnosis, medical background, 
histological and radiological data, treatment data, intra-operative images and/or videos, spectroscopic 
data. 
Electronic Transfer by magnetic or optical media, email or computer networks, use of 
audio/video recording devices, storage of personal data will be undertaken by the researchers who 
are also clinical care team responsible for direct care, at CXH. Pseudo-anonymized data will be 
transferred to the University computers by the clinical researchers and will be processed by College 
researchers either on College Computers in SK, SMH or HH. 
In case a participant, who has given informed consent, loses capacity to consent during the 
study, the participant would be withdrawn from the study. Identifiable data or tissue already collected 
with consent would be retained and used in the study. No further data or tissue would be collected or 
any other research procedures carried out on or in relation to the participant. 
Signed consent forms will be archived inside the patients' medical records and will be 
available for any audit and research quality control activities. Any identifiable data will be kept under 
Imperial College policy for 10 years including the consent form and the coded list. Patients will be 
given a copy of the signed consent form. A manual copy of the consent form will be retained in the 
Trial Master File (TMF) ONLY. No other copies will be done or retained. 
 
8.4. INDEMNITY 
Imperial College London holds negligent harm and non-negligent harm insurance policies which apply to this 
study. 
 
8.5. SPONSOR 
Imperial College of London will act as the main Sponsor for this study.  Delegated responsibilities 
will be assigned to the NHS trusts taking part in this study.   
 

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8.6. FUNDING 
Brain Tumour Research (BTR) charity is funding this study.  
 
8.7. AUDITS  
The study may be subject to inspection and audit by Imperial College London under their 
remit as sponsor and other regulatory bodies to ensure adherence to GCP and the UK Policy Frame 
Work for Health and Social Care Research.  
 
 
9. STUDY MANAGEMENT 
The day-to-day management of the study will be co-ordinated through Mr Giulio Anichini, 
Clinical Research Fellow and PhD Student – g.anichini@nhs.net, g.anichini@imperial.ac.uk 
 
 
10. PUBLICATION POLICY 
This study will follow the Imperial College of London publication policies and anti-
plagiarism guidelines. Non-identifiable data will be used during publication. Authorships and authors 
order will be defined in due course. We will collect spectral data up until the statistical model used 
for multivariate analysis does not longer improve the degree of accuracy.  
 
 
 

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11. GANTT CHART 
TASK 
01/20 
04/20 
07/20 
10/20 
01/21 
04/21 
07/21 
10/21 
01/22 
04/22 
7/22 
10/22 
Ethics 
approval 
x 
x 
 
 
 
 
 
 
 
 
 
 
Recruitme
nt 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Data 
analysis 
and write 
up 
 
 
 
 
 
 
 
 
 
x 
x 
x 
 
 
12. REFERENCES 
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simultaneous multimodal MRI and PET study. NMR Biomed. 2017 Nov;30(11).  
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and hemodynamic evaluation of gliomas using positron emission tomography. J Nucl Med. 1987 
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3. Rodgers ZB, Detre JA, Wehrli FW. MRI-based methods for quantification of the cerebral metabolic 
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OW. Radial, spiral and reverberating waves of spreading depolarization occur in the gyrencephalic 
brain. Neuroimage. 2014 Oct 1;99:244-55.  
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open-air intraoperative fluorescence imaging. Opt Lett. 2017 Aug 1;42(15):2964-2967. 
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9. Farberg AS, Glazer AM, Winkelmann RR, Tucker N, White R, Rigel DS. Enhanced melanoma 
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Maghami S, Smith JR, Elson DS. Multispectral imaging of organ viability during uterine 
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