Intraoperative Folate Targeted Fluorescence in Renal Cell Carcinoma
Phase: NA
Conditions: Renal Cell Carcinoma
Sponsor: Chandru Sundaram

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INTRAOPERATIVE FOLATE TARGETED FLUORESCENCE 
IN RENAL CELL CARCINOMA 
INDIANA UNIVERSITY PROTOCOL IUSCC-0546 
Title: 
Intraoperative folate targeted fluorescence in renal cell carcinoma 
Test Drug: 
OTL38: folate conjugated with a Tetrasodium salt solution 
(C61H63N9Na4O17S4, molecular weight 1414.42) (6 mg/vial) 
containing 2 mg/mL OTL38 free acid in 3 mL Water for Injection 
provided by On Target, LLC. 
Sponsor/PI: 
Chandru P. Sundaram, MD 
Professor of Urology, Director of Residency Program and Minimally 
Invasive Surgery, Department of Urology 
Indiana University 
535 N Barnhill Dr, STE 420 
Indianapolis, IN 46202 
Phone 317.948.3098 
Fax 317.944.0174 
sundaram@iupui.edu 
Co-investigators: 
Steven Kheyfets, MD 
George Sandusky, DVM, PhD 
Support: 
On Target Laboratories, LLC 
IND#: 
127848 
Date of Protocol: 
May 22, 2017 
 
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CONFIDENTIALITY 
The information contained within this report is confidential and may 
not be used, divulged, published, or otherwise disclosed without the 
prior written consent of On Target Laboratories, LLC. 
INVESTIGATOR’S AGREEMENT 
By signing below I confirm that I have read this protocol and agree: 
• To assume responsibility for the proper conduct of this study at this site 
• To conduct the study according to the procedures described in this protocol 
and any future amendments 
• Not to implement any deviation from, or changes to, the protocol without written 
approval from the Institutional Review Board (IRB), except where necessary to 
eliminate immediate hazard to the subject(s) 
• That I am aware of all updates and will comply with all applicable regulations 
and guidelines 
 
 
 
Principal investigator’s signature 
 
Date 
Chandru P. Sundaram, MD 
 
 
Principal investigator’s name (print) 
 
 
Professor of Urology, Director of Residency Program and 
Minimally Invasive Surgery, Department of Urology 
 
 
 
Principal investigator’s title (print) 
 
 
 
 
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PROTOCOL SYNOPSIS 
Primary 
Objectives: 
To explore the use of OTL38 and fluorescence imaging to visualize renal 
cell carcinoma (RCC) at the margins of resection in partial nephrectomy 
and in lymph node(s) or other metastases for radical nephrectomy. 
Secondary 
Objectives: 
To assess the specificity of tumor fluorescence obtained using OTL38 with 
folate receptor alpha positive (FRα+) renal cell carcinoma cancer lesions 
detected via immunohistochemistry 
To assess the agreement between fluorescence imaging using OTL38 and 
FRα by immunohistochemistry  
To assess the agreement between fluorescence imaging using OTL38 and 
visual/tactile assessments  
To assess inter-observer variation of tumor fluorescence images captured 
during surgery, physician rated usefulness of imaging, and safety of 
OTL38 
Study Design: 
This is a pilot, phase 2, non-randomized study in patients with RCC, 
scheduled to undergo primary, partial, or radical nephrectomy.  The current 
study will have 2 separate arms, but the data from each arm will not be 
compared with each other. 
Arm 1: patients with partial nephrectomy for localized RCC 
Arm 2: patients with radical nephrectomy and lymph node dissection for 
locally advance or metastatic RCC 
Test Drug/Dose: 
OTL38 Injection: folate analog ligand conjugated with an indole cyanine-
like green dye as a solution in vials containing 3 mL at 2 mg/mL provided 
by On Target, LLC.  Single-dose 0.025 mg/kg administered IV, less than 2 
hours prior to skin incision.  Diphenhydramine 25 mg will be given prior 
to administering the study agent. 
Duration of 
Treatment 
Patients will receive a single dose of OTL38 approximately 2 hours before 
skin incision. 
Safety assessments will occur at follow-up phone visit at 10 days (±3 days) 
and follow-up office visit at 1 month (± 14 days) 
Camera Systems The da Vinci® Fluorescence Imaging Vision System manufactured by 
Intuitive Surgical, Inc. or the VSiii 3DHD system manufactured by 
Visionsense will be used in this study to visualize OTL38-labelled tumors 
during robotic partial and radical nephrectomies. The SPY Elite Imaging 
System manufactured by NOVADAQ will be used in open radical 
nephrectomies. These systems are not approved for use with OTL38, and 
are therefore considered investigational for purposes of this study.  
 
The da Vinci® Fluorescence Imaging Vision System has integrated 
fluoresence imaging capable of providing real-time, imaging identification 
of fluorescently tagged objects.  
 
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The Visionsense VSiii system is a complete solution enabling surgeons to 
use a minimally invasive stereoscopic (3D) camera, for Neurosurgical, 
ENT, Arthroscopy (CE only), and Laparoscopy applications. The system 
has been successfully used by surgeons in a wide range of MIS procedures. 
The VSiii system has 510(k) clearance and is CE Mark approved. 
 
The SPY Elite Intraoperative Imaging System is a fluorescence imaging 
system that allows surgeons to capture, review, print and archive high-
quality fluorescence images of near infrared (NIR) emitting imaging agents 
during surgical procedures. The positioning of the Imaging Head is 
controlled by the surgeon or physician. Image sequence capture is 
accomplished at operator’s command, and images can be replayed 
immediately for review. When used in combination with indocyanine 
green, SPY Elite has indications for use that include  
• visual assessment of blood flow as an adjunctive method for the 
evaluation of tissue perfusion, and related tissue-transfer circulation in 
tissue and free flaps used in plastic, micro-, and reconstructive procedures  
• visual assessment of blood flow in vessels and related tissue perfusion 
during gastrointestinal surgical procedures  
• visual assessment of blood flow in vessels and related tissue perfusion 
during cardiovascular surgical procedures  
In all other surgical imaging applications – such as for use with targeted 
NIR imaging agent technologies – SPY Elite is designated as an 
investigational device.  
Enrollment 
Subject accrual will take up to 24 months. 
Number of 
Subjects: 
20 patients with RCC will be enrolled in this study. 
The study will consist of two arms studied simultaneously: 
• Arms 1: 10 patients with partial nephrectomy for localized RCC 
• Arms 2: 10 patients with radical nephrectomy and 
lymph node dissection for locally advance or metastatic RCC 
Number of Sites 
Single site: Indiana University Simon Cancer Center, Indiana University 
Hospital 
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Outcomes:  
Partial nephrectomy 
PRIMARY 
• Assess the presence and extent of fluorescence of cT1 RCC during 
partial nephrectomy 
SECONDARY 
• Pathologic agreement of fluorescence and FRα by 
immunohistochemistry 
• Agreement between visual and fluorescent images 
• Inter-observer agreement of laparoscopic fluorescent images (for 
blinded surgeons) 
• Surgeon opinion of usefulness of intra-operative fluorescence 
imaging-Likert scale questionnaire (Appendix A) 
• Safety (perioperative, 10 days, 1-month)- Vital signs, hematology, 
chemistry, and adverse events (NCI-CTCAE v4.0) 
Radical nephrectomy and lymph node dissection 
PRIMARY 
• Assess the presence and extent of fluorescence in regional lymph 
nodes or metastasis in patients with RCC 
SECONDARY 
• Pattern of nodal spread 
• Agreement of nodal and primary tumor fluorescence 
• Pathologic agreement of fluorescence and FRα by 
immunohistochemistry 
• Detection of RCC in primary tumor in situ  
• Agreement between visual and fluorescent images. 
• Inter-observer agreement of in-situ fluorescent images (for blinded 
surgeons) 
• Surgeon opinion of usefulness of intra-operative fluorescence 
imaging- Likert scale questionnaire (Appendix A) 
• Safety (perioperative, 10 days, 1-month)-Vital signs, hematology, 
chemistry, and adverse events (NCI-CTCAE v4.0) 
 
 
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LIST OF ABBREVIATIONS AND TERMS 
Abbreviation/Term 
Definition 
ADE 
Adverse device effect 
AE 
Adverse event 
BMP 
Basic metabolic panel 
CBC 
Complete blood count 
CMP 
Comprehensive metabolic panel 
CRF 
Case report form 
CT 
Computed tomography 
CTMS 
Clinical Trial Management System 
CTO 
Clinical Trials Office 
CTSI 
Indiana Clinical and Translational Sciences Institute 
DSMC 
Data Safety Monitoring System 
ECOG 
Eastern Cooperative Oncology Group 
FDA 
Federal Drug Administration 
FR 
Folate receptor protein 
FITC 
Fluorescein isothiocyanate 
GFR  
Glomerular filtration rate 
IDS 
Investigational Drug Service 
IHC 
Immunohistochemistry 
IND 
Investigational new drug 
IUH 
Indiana University Hospital 
IUSCC 
Indiana University Simon Cancer Center 
LND 
Lymph node dissection 
REDCap 
Research Electronic Data Capture 
RCC 
Renal cell carcinoma 
SAE  
Serious adverse event 
SEER 
Surveillance epidemiology and end results 
 
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1 
TABLE OF CONTENTS 
INVESTIGATOR’S AGREEMENT ............................................................................................................................................. 2 
PROTOCOL SYNOPSIS ............................................................................................................................................................... 3 
LIST OF ABBREVIATIONS AND TERMS ............................................................................................................................... 6 
1 
TABLE OF CONTENTS...................................................................................................................................................... 7 
2 
SCHEMA ............................................................................................................................................................................... 9 
3 
BACKGROUND ................................................................................................................................................................... 9 
3.1 
LOCALIZED RCC ............................................................................................................................................................................ 10 
3.2 
ADVANCED RCC ............................................................................................................................................................................ 10 
3.3 
RATIONALE..................................................................................................................................................................................... 11 
4 
STUDY OBJECTIVES ...................................................................................................................................................... 13 
5 
RISKS AND BENEFITS OF OTL38 .............................................................................................................................. 14 
6 
ELIGIBILITY CRITERIA ................................................................................................................................................ 16 
6.1 
INCLUSION CRITERIA FOR LOCALIZED RCC TREATED WITH PARTIAL NEPHRECTOMY ...................................................... 16 
6.2 
INCLUSION CRITERIA FOR ADVANCED RCC TREATED WITH RADICAL NEPHRECTOMY ...................................................... 16 
6.3 
EXCLUSION CRITERIA FOR BOTH LOCALIZED AND ADVANCED RCC ...................................................................................... 17 
7 
PATIENT REGISTRATION ........................................................................................................................................... 17 
8 
STUDY PROCEDURES ................................................................................................................................................... 17 
8.1 
SUMMARY ....................................................................................................................................................................................... 17 
8.2 
STUDY CALENDAR.......................................................................................................................................................................... 18 
8.3 
ASSESSMENTS BY VISIT ................................................................................................................................................................. 19 
9 
TOXICITIES TO BE MONITORED .............................................................................................................................. 24 
10 STUDY WITHDRAWAL/DISCONTINUATION ....................................................................................................... 24 
11 DRUG INFORMATION ................................................................................................................................................... 25 
11.1 
IDENTIFICATION AND DESCRIPTION OF TEST ARTICLE ............................................................................................................ 25 
11.2 
PACKAGING AND LABELING ......................................................................................................................................................... 25 
11.3 
STORAGE AND HANDLING OF TEST ARTICLE ............................................................................................................................. 26 
11.4 
STUDY DRUG ADMINISTRATION .................................................................................................................................................. 26 
11.5 
TREATMENT COMPLIANCE ........................................................................................................................................................... 26 
11.6 
DRUG ACCOUNTABILITY ............................................................................................................................................................... 26 
12 STATISTICAL CONSIDERATIONS ............................................................................................................................. 27 
12.1 
STUDY DESIGN................................................................................................................................................................................ 27 
12.2 
STUDY POPULATION ...................................................................................................................................................................... 27 
12.3 
SAMPLE SIZE................................................................................................................................................................................... 27 
12.4 
STUDY ENDPOINTS ........................................................................................................................................................................ 27 
12.5 
PARTICIPANT CHARACTERISTICS ................................................................................................................................................ 28 
12.6 
CONCOMITANT MEDICATIONS ..................................................................................................................................................... 29 
12.7 
ANALYSIS OF PRIMARY OBJECTIVE .............................................................................................................................................. 29 
12.8 
ANALYSIS OF SECONDARY OBJECTIVES ....................................................................................................................................... 29 
13 DATA FORMS AND SUBMISSION SCHEDULE ........................................................................................................ 30 
14 PATIENT CONSENT AND PEER JUDGEMENT ........................................................................................................ 30 
15 DATA AND SAFETY MONITORING PLAN ............................................................................................................... 31 
15.1 
STUDY AUDITING AND MONITORING ......................................................................................................................................... 31 
15.2 
EARLY STUDY CLOSURE ............................................................................................................................................................... 31 
15.3 
REPORTING GUIDELINES .............................................................................................................................................................. 31 
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15.4 
REPORTING DEATH ....................................................................................................................................................................... 31 
15.5 
STUDY ACCRUAL OVERSIGHT ...................................................................................................................................................... 31 
15.6 
PROTOCOL DEVIATIONS ............................................................................................................................................................... 32 
15.7 
UNANTICIPATED PROBLEMS ....................................................................................................................................................... 32 
16 ADVERSE EVENTS.......................................................................................................................................................... 32 
16.1 
DEFINITIONS OF ADVERSE EVENTS............................................................................................................................................ 32 
16.2 
ADVERSE DEVICE EFFECTS DEFINITIONS ................................................................................................................................. 34 
16.3 
ADVERSE EVENT REPORTING REQUIREMENTS: ...................................................................................................................... 34 
17 PATIENT CONSENT AND PEER JUDGEMENT ........................................................................................................ 36 
18 REFERENCES ................................................................................................................................................................... 37 
19 APPENDICES .................................................................................................................................................................... 39 
19.1 
APPENDIX A ................................................................................................................................................................................... 39 
19.2 
APPENDIX B ................................................................................................................................................................................... 47 
19.3 
APPENDIX C ................................................................................................................................................................................... 48 
19.4 
APPENDIX D ................................................................................................................................................................................... 50 
19.5 
APPENDIX E ................................................................................................................................................................................... 60 
19.6 
APPENDIX F .................................................................................................................................................................................... 62 
19.7 
APPENDIX G ................................................................................................................................................................................... 62 
19.8 
APPENDIX H ................................................................................................................................................................................... 64 
19.9 
APPENDIX I ..................................................................................................................................................................................... 65 
 
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2 
SCHEMA 
 
3 
BACKGROUND 
Renal cell carcinoma (RCC) has the highest early mortality or potential years of life lost of all 
urologic malignancies and this trend is increasing according to the recent SEER database 
analysis from 1973 to 2006 (Kamel 2012).  Computerized tomography (CT) imaging are used 
more often for detecting renal masses and has led to distinct groups of RCCs: localized (stage 
I-II) with a high cure rate and advanced (stage III-IV) with high rates of distant metastasis and 
early mortality.  Partial nephrectomy and radical nephrectomy are standard treatments for renal 
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masses. Although these options demonstrate better survival, there are uncertainties related to the 
comparative effectiveness of these treatment options (Tan 2012).  Nonetheless, surgery remains 
an integral part of the treatment strategy for all stages of RCC, and the ability to accurately 
image the disease in real time is becoming increasingly important for both localized and 
advanced disease. 
3.1 
Localized RCC 
Localized RCC is a cancer of the kidney that has not spread to the lymph nodes or distant organs.  
Improved sensitivity of CT imaging procedure has led to the increased incidence of incidentally 
diagnosed, small, low stage RCC lesions than based on the classic triad of symptoms (hematuria, 
palpable mass, and pain) that occurs in less than 15% of RCC cases (Palapattu 2002).  According 
to a study using the data form the National Cancer Database, a greater proportion of newly 
diagnosed patients with RCC present with localized RCC (lower stages) than in earlier years.  
The number of patients with Stage 1 localized RCC increased from 55% in 1993 to 67% in 2004 
Kane 2008). 
Sparing renal parenchyma in addition to cancer control has traditionally been viewed as an 
important and an unmodifiable variable in surgical treatment, especially in organ-sparing surgery 
or partial nephrectomy of localized RCC. Although healthy parenchymal safety margin during 
conservative renal surgery is still the standard of care, the risks of significant complications 
increase with the technical complexity of the case. 
Limiting ischemia time has been used as an important modifiable factor during partial 
nephrectomy.  Recent studies show that preoperative glomerular filtration rate (GFR) and 
percentage of parenchyma spared are the best predictors of long term GFR (Lane 2011; Simmons 
2011).  At the same time, the size of the safety margin during partial nephrectomy has not been 
effective in predicting recurrence (Berdjis 2006). Tumor enucleation for RCC (resecting along 
the pseudocapsule of the tumor instead of obtaining a safety margin) has been tried to spare renal 
parenchyma, limit blood loss, and resect anatomically challenging tumors.  Contrasting results 
have been reported in studies relating the effectiveness of enucleation versus partial nephrectomy 
(Minervini 2009; Minervini 2011). Acceptance of enucleation has been slow due to the rate of 
pseudocapsule invasion and concern over incomplete tumor removal. 
Minimally invasive treatment options for localized RCC include both standard laparoscopy and 
robot-assisted laparoscopic approaches. Robotic partial nephrectomy made up only 11.5% of all 
partial nephrectomies in 2008 (Yu 2012), but increased to nearly 40% by 2011 (Data not 
published from Nationwide inpatient sample).  Therefore, we propose meeting this challenge by 
combining robotic surgery with novel means of targeted real-time imaging of RCC —folate 
tagged fluorescence —to confidently spare renal parenchyma while achieving 100% tumor 
removal.  We propose evaluating folate-targeted fluorescence of the renal mass to see if it can be 
used as a real-time guide to surgeons during partial nephrectomies. 
3.2 
Advanced RCC 
Between 1990 and 2006 the death rate decreased 21% on average for all malignancies in the US, 
but for kidney cancer it decreased by 6.9% (Jemal 2010).  This placed kidney cancer 11th out of 
the 16 reported malignancies in the SEER database in terms of improving death rate.  Despite the 
introduction of several new systemic therapies for advanced RCC, there are limited options that 
offer a reliable complete response.  Cytoreductive nephrectomy continues to be the standard of 
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care, but the role for lymph node dissection is under investigation.  We propose investigating the 
ability of real-time targeted imaging with folate tagged fluorescence to determine who should 
undergo lymph node dissection (LND) and the extent of that dissection. 
Of those undergoing nephrectomy for localized disease, up to 18% will have recurrence or 
progression (Crispen 2008).  Theoretically, many of these could benefit from a LND.  However, 
as partial nephrectomy replaces radical nephrectomy for larger tumors, arguably fewer LNDs 
will be performed. Although previous studies have concluded that a LND can provide a durable 
progression free survival, the criteria for selection of patients who will most likely benefit from a 
LND remains a challenge (Delacroix 2011).  
Templates for LNDs continue to vary based on surgeon preferences, however, a recent study 
examined the predictability of 5 previously identified high-risk pathologic features on lymph 
node metastases prior to developing surgical template for LNDs (Crispen 2008). Patients with 2 
or more of the 5 criteria previously identified by Blute et al (Blute 2004) — nuclear grade 3 or 4, 
presence of a sarcomatoid component, tumor size ≥10 cm, tumor stage pT3 or pT4, and 
histological tumor necrosis— were considered high-risk for nodal metastases. A total of 64/169 
(38%) patients had positive lymph nodes.  The lymph node positivity rate was directly 
proportional with the number of criteria identified: 20%, 39%, 49%, and 50% for 2, 3, 4, and 5 
criteria present, respectively.  Lymph node spread was assessed by examining 5 different landing 
zones (right hilar, pre-caval, inter-aortocaval, pre-aortic, and left hilar).  For right-sided tumors, 
45% of positive cases had a lack of hilar region involvement.  So, if only the hilar nodes (those 
closest to the kidney) were sampled, then 45% of positive node cases on the right would have 
been missed.  The hilar nodes are the easiest to remove surgically during an LND and are often 
the only nodes removed.  Intraoperative imaging of tumors can enable surgeons to visualize and 
perform LNDs that could result in improved clinical outcomes. 
3.3 
Rationale 
In 1989 Phil Low and graduate researchers at Purdue University began looking at the possibility 
of vitamins to act as a “Trojan horse” model and deliver targeted agents to cancer cells.  His lab 
has continued this quest with one of the most promising agents being the vitamin folate.  As Sega 
and Low et al note, folate fulfills many of the ideal characteristics for targeted agents: the folate 
receptor protein (FR) is upregulated in many cancer cells, while having limited expression on 
normal tissues, folate has a high affinity for the FR meaning saturation at low doses, folate 
conjugates are taken into the cancer cells by endocytosis, folate has a rapid clearance from the 
body cutting down nonspecific background noise during imaging (t½ <10 min), folate’s small 
size allows complete penetration of solid cancers, and folate’s chemistry allows for attachment of 
nearly any therapeutic or imaging agent for delivery to cancer cells (Sega 2008).  In one of its 
first applications, platinum resistant ovarian cancer, folate is being used to deliver therapeutic 
agents.  It is the only treatment to improve progression free survival (22 vs. 12 weeks) in this 
population when compared to standard treatment (Naumann 2011).  
While first purified as a tumor marker for ovarian cancer, Dr. Low has shown FR to be 
upregulated in numerous epithelial malignancies.  Parker and Low et al demonstrated that RCCs 
are the second highest FR expressing cancer with 86% falling into the high positive category 
using a radioligand method (Parker 2005).  There was some variability in expression within 
RCCs.  Normal kidney proximal convoluted tubule cells also contained the FR on the apical and 
basal membranes, which is thought to either conserve or secrete plasma folate depending on the 
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needs of the body (Morshed 1997).  Therefore, normal kidney cells are not expected to 
accumulate folate like cancer cells (0A). 
A conjugate of Dr. Low’s lab, folate and 99mTc, was recently used for SPECT imaging in 154 
patients with proven or suspected cancer, of which 118 were RCC.  In the RCC group 74% had 
mild or marked uptake of tracer in one or more lesions.  For all cancer types, when comparing 
tracer uptake with immunohistochemistry (IHC) of previous or subsequent surgical specimens 
there was a 61% overall agreement.  This was thought to be due to the IHC being specific for 
only one isoform of the FR or heterogeneity of FR expression between cancer lesions in the same 
patient (Fisher 2008).  The agent was found to be safe and well tolerated. 
Figure 1. Representative SPECT image and Immunohistochemical Staining of RCC 
 
Increased uptake is demonstrated in RCC (red arrow) versus normal kidney (green arrow) on SPECT imaging 
with a folate 99mTc conjugate after 1-hour (A).  Quantification of tumor deposits ex vivo was done by 
comparing color images with the corresponding tumor-specific fluorescent image (B). 
Another conjugate of Dr. Low’s lab, folate-fluorescein isothiocyanate (EC-17, folate-FITC), has 
been synthesized for in vivo visualization of tumor cells.  Taking advantage of the extensive 
localization of receptors for folate on cancer cells, the bound agent is removed from circulation 
through endocytosis by the cancer cells and not available for redistribution in the body.  Studies 
in ovarian cancer showed improved detection of metastatic lesions (Figure 1, van Dam 2011).  
However, EC-17 is not optimal as the wavelength emitted (520 nM) is in the visible spectrum 
with minimal ability to penetrate deeply through tissue. 
Dr. Low’s lab recently developed OTL38, which is a folate analog conjugated with a fluorescent 
dye that emits light in the near infrared spectrum (near 800nm).  This longer wavelength allows 
for deeper penetration of the fluorescent light through tissues with the potential to better image 
tumors beneath adipose tissue or deeper into organ parenchyma.  A phase 1 trial was recently 
completed showing only mild adverse events at drug concentrations appropriate for further phase 
2 trials.  
Renal cell carcinoma is the only urologic malignancy that is increasing in both incidence and 
early mortality.  Surgery is an integral part of the treatment strategy for all stages of RCC, and 
the ability to accurately image the disease in real time is becoming increasingly important for 
both localized and metastatic disease. 
Folate targeted imaging was recently developed due to many compelling characteristics:  the 
folate receptor α is up regulated in up to 75% of RCCs, incorporates the folate conjugate into the 
cancer cell by endocytosis, and has limited expression on normal cells.  Multiple folate 
conjugates are being tested for staging, intraoperative imaging, and drug delivery and are 
showing unmatched survival benefits in platinum resistant ovarian cancer.    
For localized RCC (stage I-II), the limits of renal sparing surgery are being explored to preserve 
healthy nephrons.  Studies show that the percentage of parenchyma spared during partial 
nephrectomy is the best predictor of postoperative renal function.  Folate targeted fluorescent 
imaging offers the ability to see tumor at the resection margin.  The hypothesis is that folate 
imaging will correlate with final pathology at the border of the tumor and therefore be a 
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dependable guide for robotic resection.  Additional hypotheses are that there will be strong 
agreement between surgeons on what has positive fluorescence, surgeons will find the folate 
imaging useful during resection and the procedure will be safe. 
For advanced RCC (stage III-IV), folate imaging offers a better chance of complete resection 
than other treatment options currently available.  While level-1 evidence within the literature 
shows LND in stage I-II RCC has no therapeutic benefit, its role in Stage III-IV disease may 
show some benefit (Blom 2009).  Some groups advocate risk-stratifying of RCC using 
intraoperative frozen section analysis, which adds considerable cost and time to the surgery.   
Intraoperative imaging of FR could improve selection for LNDs and provide real time guidance 
for the surgical template used.  Overall, this will be the first study to use folate targeted 
intraoperative imaging of RCC to improve clinical outcomes.  Data obtained from the proposed 
pilot study will help develop future protocols with large sample sizes and accurately estimate 
sensitivity, specificity, positive predictive value, and negative predictive value of OTL38. 
4 
STUDY OBJECTIVES 
Primary 
• To explore the use of OTL38 and fluorescence imaging to detect RCC in partial 
nephrectomy at the margins of resection, and in lymph node(s) or other metastases during 
radical nephrectomy. 
Secondary 
 To assess the specificity of tumor fluorescence obtained using OTL38 with FRα+ renal cell 
carcinoma cancer lesions detected via immunohistochemistry 
• To assess the agreement between fluorescence imaging using OTL28 and FRα by 
immunohistochemistry 
• To assess the agreement between fluorescence imaging using OTL38 and visual/tactile 
assessments  
• To assess the pattern of (lymph) nodal spread during radical nephrectomy 
• To assess the degree of agreement of (lymph) nodal and primary tumor fluorescence during 
radical nephrectomy 
• To assess the detection of RCC in primary tumor in situ during radical nephrectomy  
• To assess inter-observer variations of tumor fluorescence images captured during surgery 
• To assess physician rated usefulness of intra-operative fluorescence imaging- Likert scale 
questionnaire (Appendix A) 
• To assess the safety of OTL38 (perioperative, 1-month)- Vital signs, hematology, 
chemistry, and adverse events (NCI-CTCAE v4.0) 
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5 
RISKS AND BENEFITS OF OTL38 
5.1.1 
Risks 
The issues of possible concerns with the use of the OTL38 and the imaging system are: 
• Presence of an imaging system in the operating room 
• Phototoxicity or thermal damage from the light source 
• Nonspecific localization of OTL38 
• Failure of OTL38 to bind to receptors 
• Fading of the chromophore (photobleaching) 
• Inability to excite the dye in OTL38 or to record emission 
• Adverse events suggestive of hypersensitivity 
5.1.1.1 Imaging system 
The presence of an imaging system in the operating room is not novel and should not create a 
problem with maintaining a sterile field.  In this case, the camera system will be used for intra-
operative imaging prior to surgical resection to record the localization of tumors, and post-
resection to document the visualization of any residual tumor.  As such, it need not be intrusive 
during the procedure.  Standard operating room procedures to ensure a sterile milieu, including 
appropriate draping of the imaging system, will be employed. 
There is a potential for phototoxicity or thermal damage from any light source.  The degree of 
risk is related to the power of the light, the duration of exposure, and the temperature of the light 
source near the patient.  The maximum temperature and irradiance for the imaging system are 
well within established safety limits.  Controls will be in place to ensure that the exposure to the 
imaging system is limited to that is necessary to identify the tumor lesions and capture images. 
Like all chromophores (fluorophores), excitation by appropriate wavelength of light will result in 
molecular activation resulting in a different wavelength of light being emitted.  This is an active 
process that changes the excitability of the molecule potentially leading to photobleaching.  
Since white light contains all wavelengths of light, extended room light exposure could lead to 
bleaching. Exposure to the excitation light source will be limited during the procedure.  
According to van Dam et al. (2011), the initial images can be captured in a mean time of 
10 minutes (4-36 minutes), and tumor-specific fluorescence can be detected for up to 8 hours. 
The risk that the camera system will not excite the OTL38 dye or record an image after emission 
is minimal.   
5.1.1.2 OTL38 
While OTL38 appears to specifically localize RCC, there is a possibility that some 5-10% of 
patients will have and will not benefit from use of this agent.  The risk of exposure to OTL38 to 
these patients FR-alpha-negative tumors and to patients without cancer appears small.   
There is no evidence to date to indicate failure of OTL38 to bind to FRα, so this remains a 
theoretical concern. Possible mechanisms would be competitive antagonism with another ligand 
(eg, folate) or a change in the molecule or receptor to hinder binding. 
The rat and dog were selected as the rodent and non-rodent toxicology species for the OTL0038 
toxicology program. While all studies showed that test article related green(ish) discolorations 
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may occur with OTL0038, which is an opaque, dark green liquid following formulation, these 
discolorations were not signs of irritation or associated with toxicological findings (see 
investigator brochure). In in-vivo safety toxicology and safety pharmacology studies, doses as 
high as 30.8 mg/kg in Sprague Dawley rats and 13.9 mg/kg in Beagle dogs (>500X the proposed 
human starting dose of 0.025 mg/kg), were well tolerated and resulted in no adverse effects. 
A phase 1a study was conducted on 30 healthy controls with 23 receiving OTL38 and 7 acting as 
placebo by 3:1 randomization. A single dose IV administration of 0.025, 0.05, 0.1, or 0.2 mg/kg 
was given.  No serious adverse events or death occurred.  A total of 83 mild and moderate AEs 
were noted in the 23 patients receiving OTL38. With the exception of sleepiness (somnolence), 
all were suggestive of hypersensitivity reactions and no adverse events were cardio-pulmonary in 
origin.  The most frequent adverse events (AEs) were nausea (11/23, 47.8%), pruritus (9/23, 
39.1%), abdominal discomfort (8/23, 34.8%), somnolence (8/23, 34.8%), and dizziness (5/23, 
21.7%). One treatment was stopped after a 15% infusion (treatment #5) and one had infusion 
held prior to completion.  Initial drug infusion was 20 mL infused over 10 minutes. However, the 
protocol was changed to 220 mL over 60 minutes in response to early moderate AEs. After the 
infusion was changed to 220 mL over 60 minutes, only mild AEs were observed and no infusion 
was stopped or held up for those receiving 0.1mg/kg or less. 
Intravenous infusion over 60 min of 0.025 and 0.05 mg/kg OTL38 in a total volume of 220 ml 
5% dextrose (D5W) to healthy volunteers was associated with mild adverse events that did not 
require any intervention, were not considered to be clinically significant, and there appeared to 
be no relationship to an increase in dose.     
5.1.2 
Benefits 
The potential benefits of OTL38 imaging are: 
• Improved staging of the tumor 
• Removal of more lesions  
• Added assurance of clean margins to excised tumors. 
In a preliminary study of ovarian cancer by van Dam et al (Van Dam 2011), significantly more 
lesions were detected by surgeons using Folate-FITC than with visual observation alone (34 vs. 
7; p < 0.001). Lesions that were as small as 1 mm could be detected and removed. This resulted 
in better staging of patients as more lesions could be visualized but, more importantly, it resulted 
in greater tumor debulking. Since the degree of tumor removal directly affects the prognosis, this 
was a large potential benefit. This would need to be studied with OTL38.  Use of OTL38 would 
not change the surgeon’s option to remove additional tissue because of impressions based on 
experience, visualization, or tactile senses. 
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6 
ELIGIBILITY CRITERIA 
6.1 
Inclusion criteria for localized RCC treated with partial nephrectomy 
To be considered eligible to participate in this study, a patient must meet all the inclusion criteria 
listed below: 
• ≥ 18 years of age. 
• Have primary or suspected diagnosis of RCC, with presence of cT1-2 renal mass by 
diagnostic CT assessment. 
• Scheduled for partial nephrectomy of renal mass. 
• Expected survival of at least 3 months. 
• Written informed consent available. 
• ECOG ≤ 1 (Appendix G). 
• Negative serum or urine pregnancy test within 24 hours for females of child bearing age 
• Recovered from toxicity of any prior therapy to ≥ grade 1.  
6.2 
Inclusion criteria for advanced RCC treated with radical nephrectomy 
To be considered eligible to participate in this study, a patient must meet all the inclusion criteria 
listed below: 
• ≥ 18 years of age. 
• Have pathologic or suspected diagnosis of RCC with presence of cT1-4 renal mass and 
evidence of nodal or metastatic involvement by diagnostic CT assessment 
• Scheduled for radical nephrectomy and lymph node dissection. 
• Expected survival of at least 3 months. 
• ECOG ≤ 2. 
• Negative serum or urine pregnancy test within 24 hours for females of child bearing age. 
• Recovered from toxicity of any prior therapy to ≥ grade 1  
• Written informed consent available. 
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6.3 
Exclusion criteria for both localized and advanced RCC 
• History of any anaphylactic reaction, any severe allergy, or any allergy to folate. 
• Brain metastases 
• Baseline GFR < 50 mL/min/1.73m2)  
• Hepatic toxicity ≥ Grade 2 (using CTCAE version 4 standard definitions). 
• Participation in another investigational drug trial either concurrently or 30 days prior to 
surgery 
• Any medical condition that in the opinion of the investigators could potentially 
jeopardize the safety of the patient, limit the patient’s ability to complete the study, 
and/or compromise the objectives of the study. 
• Known sensitivity to fluorescent light 
7 
PATIENT REGISTRATION 
Patient enrollment will take place over 24 months at a single institution-Indiana University 
Simon Cancer Center (IUSCC)/Indiana University Hospital (IUH).   
All patients will be registered with the Indiana University (IU) Department of Urology. 
Regulatory files will be maintained by the Department of Urology. Applicable regulatory 
documents must be completed and on file prior to registration of any patients. Potential patients 
will be identified in the Urology clinic or by physician referrals. Patients who appear to be 
eligible for this trial will undergo the Informed Consent Process and be screened for eligibility 
utilizing the Eligibility Criteria. Individual patient registration will be done in the OnCore® 
database. The original signed Institutional Review Board (IRB) approved Informed Consent 
Document and completed eligibility checklist will be stored in the following location:  
 
Indiana University Medical Center 
Indiana Cancer Pavilion 
Urology Clinic, 3rd floor 
535 N. Barnhill Dr. 
Indianapolis, IN 46202 
8 
STUDY PROCEDURES 
8.1 
Summary 
Administration of the study drug will begin prior to skin incision in the preoperative area where 
safety monitoring will occur. The tumor resection occurs approximately 2 hours after being 
brought back to the operating room and so there is no wait time between infusion and being 
taken back to operating room. Intraoperative fluorescent imaging will be utilized in parallel with 
the standard operating procedure to capture images during surgery. Images also will be taken of 
the excised specimen on the back table.  The excised specimen will be sent to the pathology 
department for fluorescent imaging and immunohistochemistry for FR. Subjects will have a 
2-5 day hospital stay (normal nephrectomy recovery period) where safety measurements will be 
taken. Final safety measurements will be taken at the 10-day and 1-month follow-up visits. 
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8.2 
Study calendar 
Study 
Procedures12 
Screening 
Pre-
surgery Surgery 
Post-
surgery 
Hospital 
Admission 
Hospital 
Discharge 
Follow-
up 
Phone 
Call 
Follow-
up 
Appt 
 
Up to 90 
days prior 
to surgery 
Day 0 
Days 1-5 
Days 2-6 
Day 10 
(± 3 
days) 
1 
Month 
(±14 
days) 
Informed consent 
X 
 
 
 
 
 
 
 
Inclusion/exclusion 
criteria 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Medical history1 
X 
X2 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
X 
Height/weight 
X 
 
 
 
 
 
 
X3 
Vital signs4 
X 
X5 
X6 
X6 
X6 
X6 
 
X 
Urine/serum 
pregnancy test 
X7 
X8 
 
 
 
 
 
 
Complete 
metabolic panel 
(CMP) 
 
 
 
 
 
 
 
X 
Basic metabolic 
panel (BMP)9 
X 
 
 
 
X10 
 
 
 
CBC w/ diff  
X 
 
 
 
X10 
 
 
X 
Study drug 
administration11 
 
X 
 
 
 
 
 
 
Surgery with 
associated 
procedures 
including intra-
operative imaging 
 
 
X 
 
 
 
 
 
Tumor ex-vivo 
sample collection 
 
 
X 
 
 
 
 
 
Pathologic 
assessment 
 
 
 
X 
 
 
 
 
PI Likert 
questionnaire 
 
 
 
X 
 
 
 
 
AE assessments 
 
X 
X 
X 
X 
X 
X 
X 
ADE assessments 
 
 
X 
X 
X 
X 
X 
X 
Concomitant 
medications 
X 
X1 
X 
X 
X 
X 
X 
X 
 
Footnotes: 
1Includes past medical history, past surgical history, allergies and any ongoing medical conditions 
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2Since screening visit and up to 30 days before surgery 
3Weight only 
4Temperature, blood pressure, respiratory rate and pulse rate 
5Taken at baseline (up to 30 minutes prior to OTL38 infusion), approximately every 15 minutes 
during infusion (only blood pressure and pulse rate), and then approximately every hour after infusion 
until surgery is initiated  
6Record per institutional practice 
7Serum pregnancy test for all females of childbearing potential 
8Urine pregnancy test for all females of childbearing potential 
9Basic metabolic panel includes Na, K, Cl, Mg, Ca, BUN, creatinine  
10Obtain on day 1 after surgery  
11Single dose of anti-histamine (diphenhydramine 25 mg IV) will be administered prior to the study 
drug; study medication will be administered less than 2 hours prior to the skin incision 
12Patients from both arms will follow this schedule 
8.3 
Assessments by visit 
8.3.1 
Screening (Day -90 to Day -1): 
• Informed consent: investigators or their designees will discuss with subjects the nature of 
the study, its requirements, risks, and restrictions to obtain informed consent for 
participation in the study. Subjects should have sufficient time to review the study 
information and consent form and to ask any questions necessary to make an informed 
decision regarding their participation in the study. Written informed consent is to be 
obtained before any other study-specific procedure. 
• Eligibility criteria: make sure patient meets study eligibility criteria. 
• Demographics 
• Medical history: includes past medical history, past surgical history, allergies and any 
ongoing medical conditions 
• Medication history: all medications noted in patients record at time of screening 
• Physical examination: including height, weight, vital signs (blood pressures, heart rate, 
respiratory rate, and temperature). The extent of the physical examination is determined 
by the investigator (or designee) and is based on clinical relevance to the subject’s 
medical history and scheduled surgical procedure as per standard medical/surgical care. 
• Blood samples: complete blood count with differential (CBC w/ diff) and basic metabolic 
panel (Na, K, Cl, Mg, Ca, BUN, creatinine), and serum pregnancy for women of 
childbearing age 
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8.3.2 
Surgery (Day 0): 
8.3.2.1 Pre-surgery:  
• Eligibility criteria: ensure subject continues to meet study eligibility 
• Medical history: capture additional medical history since screening 
• Concomitant medications: record medications taken since screening through day of 
surgery. All preoperative medications (this does not include normal saline or other 
routine maintenance intravenous fluids) will also be recorded. 
• Urine pregnancy test: for women of childbearing age 
• Vital signs (blood pressures, heart rate, respiratory rate, and temperature): will be taken at 
baseline (up to 30 minutes prior to infusion), approximately every 15 minutes during 
infusion (blood pressure and pulse rate), and then approximately every hour after infusion 
until surgery is initiated.  During and post-surgery these will be recorded per institutional 
practice. 
• Study drug administration:  
o A single dose of anti-histamine (diphenhydramine 25 mg IV) will be 
administered prior to the study drug. 
o Begin administration of study medication less than 2 hours prior to the 
skin incision on day of surgery in the preoperative area. 
o Record time of study medication administration 
o Record time of scheduled surgery (listed operating room time) 
• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) noted after the start of the study medication that was not 
present at screening. 
8.3.2.2 Surgery: 
The da Vinci® Fluorescence Imaging Vision System, SPY Elite Imaging System or 
Visionsense VSiii 3DHD system will be used to identify tumor lesions under 
normal/visible light and fluorescent light prior to surgical excision of lesions, and again 
after surgical excision of lesions to identify persistent lesions. The da Vinci system or 
Visionsense VSiii system will be used for all partial nephrectomies (robotic) and for 
robotic radical nephrectomies. The SPY Elite will be used for open radical 
nephrectomies. See Appendix D and Appendix E for more detailed information about 
the da Vinci and SPY camera/imaging systems. Information about the Visionsense VSiii 
system can be found at http://www.visionsense.com/vsiii-system/.  
The Investigator will record the start and stop time for each exposure to fluorescence 
(pre-resection, post-initial resection, other [give reason]) in the eCRF. The total time of 
fluorescence will be calculated automatically.  
 
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Status 
Time On 
Fluorescent Light 
Time Off 
Fluorescent Light 
Before surgical excision 
 
 
After initial surgical excision 
 
 
Other (explain reason) 
 
 
The number and location of suspect tumor lesions detected under normal light and/or 
by palpation will be recorded on the schematic (Appendix B) using an “O”. The 
number and location of suspect tumor lesions detected using fluorescent light will be 
recorded on the schematic using an “x” (for those lesions that were also identified under 
normal light and/or by palpation, the “x” will be superimposed on the “O” as “”; and 
for those identified only under fluorescence, they will be recorded only by the “x”). 
Light source 
Notation 
Visible light 
O 
Fluorescent 
X 
Both 
 
 
For Partial Nephrectomies 
Surrounding perinephric fat will be removed as indicated for the renal mass. Then the 
renal mass will be visualized and photographed (video and still images) using visible 
light and fluorescent light. As described above, start and stop times of exposure to 
fluorescent light will be noted, and the number and location of fluorescent lesions related 
to the mass and surrounding renal parenchyma detected will be recorded on the 
schematic. Findings under visible light will also be recorded.  
After the renal mass is removed, it will be processed by the operating surgeon and the 
frozen section pathology staff. The tumor margin will be inked and the tumor sectioned 
in 5mm thick cross-sectional slices. The tumor will then be returned to the operating 
room to be viewed and photographed with visible and fluorescent light. It will then be 
sent for pathologic processing as discussed in Appendix B. 
For Radical Nephrectomies 
The regional lympadenectomy will be performed as per the standard of care for the 
patient’s renal mass. The renal mass will be visualized and photographed (video and still 
images) using visible and fluorescent light through the surrounding perinephric fat. The 
start and stop times of exposure to fluorescent light will be noted, and the number and 
location of fluorescent lesion/s related to the mass and surrounding renal parenchyma 
detected under fluorescent and visible light sources will be recorded on the schematic.  
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All identified nodal tissue from each marking (“O”, “X”, and “”) will be excised, as 
determined by the Investigator, under normal light. Following the initial excision under 
normal light, the field will be illuminated with fluorescent light again to detect any 
remaining fluorescence-positive lesions. Any such lesions will be noted with a “P” on a 
schematic sheet (Appendix C) and excised as determined by the Investigator. A unique 
identifier will be assigned to each excised lesion, and the location for each lesion will be 
recorded on the schematic and in the eCRF. The reason for not excising any remaining 
lesion(s) will be noted. If no additional lesions are observed, this will be noted on the 
schematic and in the eCRF. 
The nodal tissue will be processed by the operating surgeon and the frozen section 
pathology staff. The lymph nodal tissue will be marked with suture or clips to help with 
anatomic orientation of the specimen, and then sent for pathologic processing as 
discussed in the study pathology manual. 
 To further assess agreement of gross fluorescence with pathology, at least one 
representative lymph node biopsy done. Once the specimen is removed, it will be 
processed by the surgical team on the back table and sent to pathology for microscopic 
examination and immunohistochemistry assessment to determine if it contains FRα+ 
cancer cells. The pathologist will be blinded to the fluorescence results of the tumor.  
For All Surgeries 
• Vital signs: recorded per institutional practice 
• AE assessment: including hypersensitivity reactions, which could include skin 
reactions, difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, 
redness, tenderness, pain, or rash at the injection site or any clinically relevant 
abnormality (with exception of surgical scars) that was not present at screening. 
• Adverse device effects (ADE) assessment: the surgeon will examine the subject to 
confirm that there are no visible changes to skin (erythema or pigment darkening), 
tissue or organs related to fluorescence. Changes could be present but are likely due 
to the temperature of the cauterization as lesions are excised.  
• Concomitant medications: record all intraoperative medications (this does not include 
normal saline or other routine maintenance intravenous fluids)  
8.3.2.3 Post-surgery: 
• Post-surgery questionnaire: the surgeon will complete a questionnaire describing the 
usefulness of the fluorescence imaging for tumor removal and to achieve a negative 
margin (Appendix A).  
• Blinded surgeon assessment: A co-investigator, blinded surgeon who was not involved 
with the case will view the photographs and complete a questionnaire to assess inter-
observer agreement (Appendix A). 
• Type of RCC excision (radical, partial), need for blood transfusion and estimated blood 
loss 
• Vital signs: recorded per institutional practice 
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• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) that was not present at screening. 
• ADE assessment: the surgeon will examine the subject to confirm that there are no visible 
changes to skin (erythema or pigment darkening), tissue or organs related to fluorescence. 
• Concomitant medications: record all postoperative medications (this does not include 
normal saline or other routine maintenance intravenous fluids) 
8.3.3 
In-hospital admission (Days 1-5): 
• Blood samples: complete blood count w/ differential (CBC w/ diff) and basic metabolic 
panel (BMP) on day 1 after surgery 
• Vital signs: recorded per institutional practice 
• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) that was not present at screening. 
• ADE assessment: the surgeon will examine the subject to confirm that there are no visible 
changes to skin (erythema or pigment darkening), tissue or organs related to fluorescence. 
• 
Concomitant medications: record all postoperative medications (this does not include 
normal saline or other routine maintenance intravenous fluids) 
8.3.4 
Hospital discharge (Day 2-6): 
• Vital signs: recorded per institutional practice 
• Review records relating to discharge: date and time that discharge order was written 
(must occur the same day) 
• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) that was not present at screening. 
• ADE assessment: the surgeon will examine the subject to confirm that there are no visible 
changes to skin (erythema or pigment darkening), tissue or organs related to fluorescence. 
• Concomitant medications: record all postoperative medications (this does not include 
normal saline or other routine maintenance intravenous fluids) 
8.3.5 
Follow-up phone call (Day 10 [±3 days]): 
• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) that was not present at screening. 
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• ADE assessment: the surgeon will examine the subject to confirm that there are no visible 
changes to skin (erythema or pigment darkening), tissue or organs related to fluorescence. 
• Concomitant medications: record any new medications taken since discharge 
• A letter will be sent to any subject not contacted after 3 attempts by telephone 
8.3.6 
Follow-up appointment (1 Month [± 14 days]): 
• Physical examination: including weight and vital signs (blood pressures, heart rate, 
respiratory rate, and temperature). The extent of the physical examination is determined 
by the investigator (or designee) and is based on clinical relevance to the subject’s 
medical history and scheduled surgical procedure as per standard medical/surgical care. 
• Blood samples: complete blood count with differential (CBC w/ diff) and complete 
metabolic panel (CMP) 
• AE assessment: including hypersensitivity reactions, which could include skin reactions, 
difficulty breathing, eye or nasal reactions, or gastrointestinal complaints, redness, 
tenderness, pain, or rash at the injection site or any clinically relevant abnormality (with 
exception of surgical scars) that was not present at screening. 
• ADE assessment: the surgeon will examine the subject to confirm that there are no visible 
changes to skin (erythema or pigment darkening), tissue or organs related to fluorescence. 
• Concomitant medications: record any new medications since discharge or follow-up 
phone call 
9 
TOXICITIES TO BE MONITORED 
The safety measures included in this study are standard for studies of investigational drugs.  
Additional monitoring following administration of study drug is due to screening for a 
hypersensitivity reaction after administration of OTL38 and for any adverse events that might be 
related to fluorescent imaging. 
Any clinically relevant abnormality (with exception of surgical scars) noted after the start of the 
study medication that was not present at the screening should be recorded as an adverse event 
(AE).  
On Target, LLC will be notified of any serious adverse events (SAEs) that occur and are felt to 
be due to the investigational drug by the investigators.  
More details about AEs and SAEs can be found in Section 15. 
10 STUDY WITHDRAWAL/DISCONTINUATION 
Subjects must be discontinued from the study for the following reasons: 
• Pregnancy 
• Withdrawal of consent 
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• Investigator deems withdrawal necessary at any time if it is determined that it is not in the 
subjects best interest to continue or if the subject is found to be noncompliant with study 
procedures. 
If subject discontinues after administration of study drug, he or she will be encouraged to 
continue on study for safety procedures per protocol. Reason(s) for discontinuing must be clearly 
documented in the appropriate source documents. 
11 DRUG INFORMATION 
11.1 Identification and description of test article 
OTL38 will be supplied in vials containing 3.0 mL of solution of 2 mg/mL OTL38 for a total of 
6 mg of drug per vial. 
Study medication should be stored in a freezer at temperature -20°C and with protection from 
light. 
IU Health Investigational Drug Services (IDS) will prepare the IV solutions according to 
instructions provided by On Target Laboratories at the assigned dose. All solutions should be 
protected from light. 
11.2 Packaging and labeling  
The study medication will be packaged in vials and labelled by the Sponsor’s clinical supplies 
designee. 
The vial label will include:  
 
 
 
 
 
 
The outer package label will have the following information: 
 
Study: 
Batch 20802.001Z 
OTL38 (6mg in phosphate buffer saline 3ml 
Store at -15°C to -25°C 
For Clinical Trial Only, Keep out of reach of children 
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11.3 Storage and handling of test article 
Study medication should be stored in a freezer at -20°C temperature and with protection from 
light. 
11.4 Study drug administration  
OTL38 will be prepared following the Dose Preparation for OTL38 Injection Pharmacy Manual 
(see Appendix I). OTL38 will be administered intravenously over approximately 60 minutes, 
less than 2 hours before surgery. If the patient develops any symptoms or signs suggestive of a 
hypersensitivity reaction, the infusion may be interrupted and then resumed based on the clinical 
judgement of the investigator on the condition of the patient. 
Note that OTL38 should not be mixed with other medicinal products and should not be given 
simultaneously through the same IV line as another medicine. 
11.5 Treatment compliance 
All doses of study medication must be prescribed as a written order on each subjects’ medical 
chart in order for IDS to dispense study medication.  All doses of study medication are to be 
administered under the direction of the investigator or physician trained by the investigator. 
11.6 Drug accountability 
The pharmacist or designee will sign for receipt of study medications upon delivery to IDS.  
Study medications are to be dispensed only for those subjects formally entered into the study.  
The actual dosing time of study medication is to be properly documented in the hospital 
medication administrative record.   
At the end of the study, these records will be used to account for all study medication.  After 
drug accountability is reconciled, all unused study medication will be disposed of according to 
IDS Standard Operating Procedures. 
On Target Laboratories, LLC,  
West Lafayette, IN 47906 
Tel (765) 588-4547  
Route of administration: injection 
Quantity supplied: 6 mg OTL38 per vial 
Pharmaceutical dosage form: Phosphate Buffered Saline (pH 7.4) 
Storage conditions: keep frozen at temperature -20°C 
CAUTION: New Drug – Limited by Federal Law to Investigational Use 
Lot number: 20802.001Z 
Manufacturing date: 08 October 2013 
Retest date: October2015 
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12 STATISTICAL CONSIDERATIONS 
Statistical analysis of this study will be the responsibility of the Biostatistics and Data 
Management Core at the Indiana University Melvin and Bren Simon Cancer Center (IUSCC). 
Parameter estimates and relevant summary statistics will be reported where appropriate. For 
continuous variables, summary statistics will include number of subjects, mean, median, 
standard deviation, minimum and maximum. Categorical endpoints will be summarized using 
number of subjects, frequency, and percentages. Missing data will not be imputed. Data analysis 
will be performed in SAS Version 9.4.  Additional exploratory analyses of the data will be 
conducted as deemed appropriate. Changes from this analysis plan will not require an 
amendment to the protocol unless it changes a significant feature of the protocol. 
The statistical analysis methods are outline below. 
12.1 Study design 
A Pilot, Phase 2, Non-randomized, Single Institution Study  
12.2 Study population 
The enrolled population comprises all patients who meet the eligibility criteria and are registered 
onto the study and who are treated on this protocol. 
12.3 Sample size 
The study consists of a total of 20 patients divided equally between two treatment arms that will 
be studied simultaneously: 
• Arm 1: 10- partial nephrectomy for localized RCC (no lymph nodes) 
• Arm 2: 10- radical nephrectomy and lymph node dissection for locally advance or 
metastatic RCC. 
A total sample size of 20 was determined to balance the competing goals of assessing the 
primary and secondary while not exposing more patients to an investigational procedure than is 
required.  Also, there is an 88% probability of seeing at least one toxicity event if the probability 
of that toxicity is 0.10. Thus, we feel confident that with a sample of size 20, we will be able to 
detect unacceptable toxicities that have probabilities of 0.10 or higher. 
A sample size of 10 for each arm was chosen.  If we do not observe sensitivity for detection of 
RCC of at least 70% in each arm, we will consider further refinement of the methodology before 
proceeding with additional larger studies. 
12.4 Study endpoints 
Partial nephrectomy 
PRIMARY 
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• Detect the presence and extent of fluorescence of cT1 RCC in partial nephrectomy 
specimens at the margins of resection. 
SECONDARY 
• To assess the specificity of tumor fluorescence obtained using OTL38 with FRα+ renal 
cell carcinoma cancer lesions detected via immunohistochemistry 
• To assess pathologic agreement between fluorescence imaging using OTL28 and FRα by 
immunohistochemistry 
• To assess the agreement between fluorescence imaging using OTL38 and visual/tactile 
assessments  
• To assess inter-observer variations of tumor fluorescence images captured during surgery 
• To assess physician rated usefulness of intra-operative fluorescence imaging- Likert scale 
questionnaire (Appendix A) 
• To assess the safety of OTL38 (perioperative, 1-month)- Vital signs, hematology, 
chemistry, and adverse events (NCI-CTCAE v4.0) 
Radical nephrectomy and lymph node dissection 
PRIMARY 
• To detect the presence and extent of fluorescence in regional lymph nodes and metastases 
in patients with RCC. 
SECONDARY 
• To assess the pattern of (lymph) nodal spread during radical nephrectomy 
• To assess the degree of agreement of (lymph) nodal and primary tumor fluorescence during 
radical nephrectomy 
• To assess the detection of RCC in primary tumor in situ during radical nephrectomy  
• To assess the pathologic agreement of fluorescence and FRα by immunohistochemistry 
• To assess the agreement between fluorescence imaging using OTL38 and visual/tactile 
assessments  
• To assess inter-observer variations of tumor fluorescence images captured during surgery  
• To assess surgeon opinion of usefulness of intra-operative fluorescence imaging-Likert 
scale questionnaire (Appendix A) 
• To assess the safety (perioperative, 1-month) of OTL38-Vital signs, hematology, 
chemistry, and adverse events (NCI-CTCAE v4.0). 
12.5 Participant characteristics 
Demographics, medical history, and physical examination characteristics will be summarized 
using descriptive statistics. 
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12.6 Concomitant medications 
Concomitant medications will be coded using the WHO Drug dictionary and will be summarized 
in tabular format. 
12.7 Analysis of primary objective 
The primary endpoint is to see if OTL38 and fluorescence imaging has sensitivity to detect RCC 
in the primary tumor (for partial nephrectomy) or in lymph nodes (for radical nephrectomy with 
lymph node dissection). Both sensitivity and the secondary endpoint of specificity will be 
assessed as follows:  Final pathology and immunohistochemistry will serve as the gold standard 
with which gross observation and fluorescent imaging are compared for margin of resection, 
regional lymph nodes, and primary tumor.  Pathology and immunohistochemistry results will be 
listed per patient. Times on and off for the imaging system will be listed per patient.  Sensitivity, 
specificity, positive predictive value, and negative predictive value will be calculated for 
descriptive purposes although we understand the sample sizes are not large enough to estimate 
these values with a high level of accuracy at this stage. That would be accomplished is a future 
larger study.  Sensitivity and specificity will be estimated using the method of Generalized 
Estimating Equations (GEE), which will take into consideration the correlated nature of multiple 
lesions removed from the same patient. Each patient will have all excised target lesions 
contributing to the data analysis (each type: O, x,, and P). 
Cancer + 
Cancer- 
Fluorescence+ 
True Positive (TP) 
False Positive (FP) 
Fluorescence- 
False Negative (FN) 
True Negative (TN) 
Sensitivity (proportion of true positives) = (TP/TP+FN) x 100 
Specificity (proportion of true negatives) = (TN/FP+TN) x 100 
 
Sensitivity will be estimated using the GEE model for binomial distribution with fluorescence (-, 
+) as the fixed effect and patients as a random effect, and the 95% lower one-sided confidence 
interval for the true sensitivity will also be estimated. Specificity will be estimated using the 
GEE model for binomial distribution with fluorescence (-, +) as the fix effect and patients as a 
random effect, and the 95% lower one-sided confidence interval for the true specificity will also 
be estimated.  Positive and negative predictive value will be estimated using similar methods. 
12.8 Analysis of secondary objectives 
Specificity:  The analysis for specificity is described above.   
Detection of RCC in primary tumor (radical nephrectomy arm only): This analyses will be the 
same as for the primary objective in the partial nephrectomy arm.  Pattern of nodal spread will be 
described qualitatively. 
Agreement between pathological agreement between fluorescence and FRα by IHC:  This 
endpoint will also be assessed by Kappa statistics (for presence/absence) or Intra Class 
Correlation (for numerical measures).  Agreement between nodal and primary tumor 
fluorescence in the radical nephrectomy arm will be assessed similarly. 
Agreement between visual and fluorescent images:  Kappa statistics will be used to assess 
agreement between visual and fluorescent images.  In addition, the number of lesions detected by 
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usual visible/tactile conditions and/or palpation vs fluorescent imaging will be analyzed using a 
paired t-test. 
Inter-observer agreement: Kappa statistics will be used to assess inter-observer agreement 
between of captured fluorescent images. 
Usefulness:  Responses to the Likert scale questionnaire completed by the surgeons will be listed 
and summarized  
Safety:  Vital signs will be summarized using descriptive statistics. Clinical chemistry, 
hematology, and urinalysis laboratory values will be listed in tabular format and those with 
above or below normal range will be identified within the table.  AEs and TEAEs will be 
summarized by body system and presented by severity and causal relationship to study drug.  
ADEs will be summarized by body system and presented by severity and causal relationship to 
study device.  Patients experiencing serious AEs or serious ADEs will be listed and summarized 
in tabular format. 
13 DATA FORMS AND SUBMISSION SCHEDULE 
Individual patient registration will be done in the OnCore® database. The OnCore® database is a 
comprehensive, web-based, Clinical Trial Management System (CTMS) which utilizes an Oracle 
database. OnCore® was developed by Forte Research Systems, Inc. and is used by the IUSCC 
Clinical Trials Office (CTO) and supported by the Indiana Clinical and Translational Sciences 
Institute (CTSI).  OnCore® properly used is compliant with Title 21 CFR Part 11.  
OnCore® provides users secure access with unique IDs/passwords and restricts access by 
assigned roles, from any location, to record, manage, and report on data associated with the 
operation and conduct of clinical trials. 
All source documents are to remain in the patient’s clinic file.  All documents should be kept 
according to applicable federal guidelines.  Clinical trial data in OnCore® are periodically 
monitored by the IUSCC Data Safety Monitoring Committee (DSMC).   
REDCap Database 
This study will utilize electronic Case Report Form completion via the secure, web-based, 
Research Electronic Data Capture (REDCap) system for data input. REDCap was developed by 
Vanderbilt University and is provided by Indiana University through their community license.  
REDCap is managed by the Indiana University Department of Biostatistics and secured by 
University Information Technology Services Advanced IT Core. Access to the password 
protected database will be limited to the investigators of this study, and any data that is 
distributed will be either de-identified or authorized by written permission from the subject. 
14 PATIENT CONSENT AND PEER JUDGEMENT 
The protocol and informed consent form for this study must be approved in writing by the 
appropriate Institutional Review Board (IRB) prior to any patient being registered on this study.   
Changes to the protocol, as well as a change of principal investigator, must also be approved by 
the Board. Records of the IRB review and approval of all documents pertaining to this study 
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must be kept on file by the investigator and are subject to inspection at any time during the study.  
Periodic status reports must be submitted to the IRB at least yearly, as well as notification of 
completion of the study and a final report within 3 months of study completion or termination.   
The study will be conducted in compliance with ICH guidelines and with all applicable federal 
(including 21 CFR parts 56 & 50), state or local laws. 
15 DATA AND SAFETY MONITORING PLAN 
Investigators will conduct continuous review of data and patient safety. Monthly review 
meetings for moderate risk trials are required and will include the principal investigator, clinical 
research specialist and/or research nurse (other members per principal investigator’s discretion). 
Monthly meeting summaries should include review of data, the number of patients, significant 
toxicities as described in the protocol, and responses observed. Summaries will be submitted and 
reviewed monthly by the DSMC (Appendix H). Submit to DSMC@iupui.edu. 
15.1 Study Auditing and Monitoring  
All trials conducted at the IUSCC are subject to auditing and/or monitoring. Reports will be 
reviewed by the full DSMC at the time of study review (Reference Risk Table in full DSMC 
Charter). 
15.2 Early Study Closure  
At any time during the conduct of the trial, if it is the opinion of the investigators that the risks 
(or benefits) to the patient warrant early closure of the study, this recommendation should be 
made in writing to the DSMC. Alternatively, the DSMC may initiate suspension or early closure 
of the study based on its review of the investigator reports.  
15.3 Reporting Guidelines  
The DSMC has streamlined the reporting process by utilizing reports from OnCore®. This has 
allowed direct view of reports within the Clinical Trials Management System (CTMS); thus 
discontinuing paper reports. SAE reports are entered into OnCore® monthly and reviewed by the 
DSMC chair and/or coordinator monthly. Findings will be reported to the full DSMC at the time 
of study review.  
15.4 Reporting Death  
Death will be reported per local IRB reporting guidelines. 
15.5 Study Accrual Oversight  
Accrual data will be entered into OnCore® system. The Protocol Progress Committee (PPC) 
reviews study accrual twice per year while the PPC coordinator reviews accrual quarterly. 
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15.6 Protocol Deviations  
Protocol deviations are entered into OnCore® and reviewed by the DSMC chair and/or 
coordinator monthly. Findings will be reported to the full DSMC at the time of study review. 
15.7 Unanticipated Problems 
Investigators are required to submit unanticipated problems to the DSMC concurrent with their 
submission of them to the IRB.  Prompt reporting of unanticipated problems to the IRB is 
defined as within 5 days for on-site studies. 
Unanticipated problems that will be reported promptly to the IRB include: 
• Major protocol deviation/violation 
• Change to the protocol taken without prior IRB review to eliminate apparent immediate 
hazard to a research subject (e.g. purposeful and for subject safety) 
• Complaint of a subject that indicates unexpected risks, or complaint that cannot be resolved 
by the research team 
• Publication in the literature, safety monitoring report, interim result or other finding that 
indicates an unexpected change to the risks or potential benefits of the research, in terms 
of severity or frequency 
• Change in FDA labeling or withdrawal from marketing of a drug, device, or biologic used 
in a research study 
• Investigator- or sponsor-initiated suspension or hold 
• Serious or continuing non-compliance 
• Adverse events (see section below) 
16 ADVERSE EVENTS 
16.1 Definitions of Adverse Events 
16.1.1 Adverse Event 
An adverse event (AE) is defined as any untoward medical occurrence associated with the use of 
a drug in humans, whether or not considered drug related. An adverse event can be any 
unfavorable and unintended sign (e.g. an abnormal laboratory finding), symptom, or disease 
temporarily associated with the use of a drug, without any judgment about causality.  Adverse 
events will be graded according to the NCI Common Toxicity Criteria, Version 4.0 (Appendix 
F). 
16.1.2 Serious Adverse Event (SAE) 
A serious adverse event is any untoward medical occurrence resulting in one or more of the 
following: 
• Results in death or ANY death occurring within 28 days of last dose of study drug (even 
if it is not felt to be drug related)  
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• Is life-threatening (defined as an event in which the patient was at risk of death at the 
time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe) 
• Requires inpatient hospitalization or prolongation of existing hospitalization 
NOTE: Hospitalizations that are not considered SAEs are:  
o Hospitalization planned prior to first administration of study drug 
o Hospitalization for elective treatment of a pre-existing condition unrelated to the 
study medication 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly or birth defect 
• Is an important medical event (defined as a medical event(s) that may not be immediately 
life-threatening or result in death or hospitalization but, based upon appropriate medical 
and scientific judgment, may jeopardize the patient or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed in the definition 
above).  Examples of such events include, but are not limited to, intensive treatment in an 
emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions 
not resulting in hospitalization; or the development of drug dependency or drug abuse. 
• Pregnancy.  Pregnancy of a patient or of the female partner of a male patient during the 
study or within 30 days after the last dose of study drug should be reported via an SAE 
report.  Should pregnancy occur in a female participant during the treatment period, study 
drug should be discontinued and OnTarget notified immediately.  Should a pregnancy 
occur in a female companion of a male participant during the treatment period, the male 
participant can continue treatment and OnTarget notified immediately.  Any such 
pregnancy is to be followed until final outcome.   
16.1.3 Unexpected Adverse Event 
An adverse event not mentioned in the Investigator's Brochure or package insert or the 
specificity or severity of which is not consistent with the Investigator's brochure or package 
insert. 
16.1.4 Determining Attribution to the Investigational Agent(s) 
Attribution: An assessment of the relationship between the AE and the medical intervention. 
CTCAE does not define an AE as necessarily “caused by a therapeutic intervention”. After 
naming and grading the event, the clinical investigator must assign an attribution to the AE using 
the following attribution categories: 
Relationship 
Attribution 
Description 
Unrelated to investigational 
agent/intervention 
Unrelated 
The AE is clearly NOT related 
Unlikely 
The AE is doubtfully related 
Related to investigational 
agent/intervention 
Possible 
The AE may be related 
Probable 
The AE is likely related 
Definite 
The AE is clearly related 
 
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16.2 Adverse Device Effects Definitions  
16.2.1 Adverse Device Effect (ADE) 
An ADE is defined as any untoward and unintended response to a medical device, in this study, 
the camera/imaging system. This definition includes any event resulting from insufficiencies or 
inadequacies in the instructions for use or the deployment of the device, as well as any event that 
is the result of a user error [ISO 14155-1:2003 (E) 3.1].  
All ADEs noted during the study will be reported in the eCRF. Please refer to section 8.3.2.2 for 
a list of possible ADEs related to the camera/imaging system. 
16.2.2 Suspected Adverse Device Effect 
A suspected ADE is a subset of all ADEs for which there is a reasonable possibility (i.e., 
evidence to suggest a causal relationship between the device and the ADE) that the device 
caused the event. Suspected ADE implies a lesser degree of certainty about causality than 
adverse device effect. 
16.2.3 Unanticipated Adverse Device Effect 
An unanticipated ADE is 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)] 
16.3 Adverse Event Reporting Requirements: 
Adverse events will be recorded from the time of first study drug administration and for at least 
30 days after treatment discontinuation, regardless of whether or not the event(s) are considered 
related to trial medications.  All AEs considered related to trial medication will be followed until 
resolution, return to baseline, or deemed clinically insignificant, even if this occurs post-trial. 
16.3.1 Reporting to the FDA: 
Per CFR 312.32 (c), the investigator-sponsor of the investigational new drug (IND) must notify 
the Food and Drug Administration (FDA) and all participating investigators in a written IND 
safety report of any adverse experience.  There are two types of reports to the FDA: 7-day and 
15-day reports. 
16.3.1.1 15-Day IND Reports:  
The investigator-sponsor of the IND must notify the Food and Drug Administration (FDA) and 
all participating investigators in a written IND safety report of any adverse experience: 
• associated with use of the drug that is both  
• serious and  
• unexpected   
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Each written notification shall be made as soon as possible, and no later than 15 calendar days 
after the investigator-sponsor’s initial receipt of the information.   
16.3.1.2 7-Day Reports: 
The investigator-sponsor must notify FDA and all participating investigators in a written IND 
safety report of any adverse experience: 
• fatal or life-threatening experience that is both 
• associated with use of the drug and 
• unexpected 
The FDA will be notified as soon as possible but no later than 7 calendar days after initial 
receipt of the information. 
Report Content: 
Each written notification may be submitted on FDA Form 3500A or in a narrative format and 
must bear prominent identification of its contents (i.e., “IND Safety Report”).  For purposes of 
this protocol, the MedWatch Report Form (FDA 3500A mandatory reporting), along with 
FDA Form 1571, and a cover letter submitted to the appropriate FDA division, will serve as 
the written IND safety report.  Follow-up information to a safety report should be submitted as 
soon as the relevant information is available. 
Submit: 
• MedWatch Report Form (FDA 3500A) 
• FDA Form 1571 
• Cover Letter 
The IUSCC Protocol Development Coordinator should be contacted to assist with all FDA 
submissions and will be provided with a copy of all events that are reported to the FDA.  All 
IND submissions will be maintained in a master file in the Clinical Research Office of the IU 
Simon Cancer Center. 
16.3.2 Reporting to the IRB:  
Unanticipated problems involving risks to subjects or others will be reported promptly to the 
IRB if they:  
• unexpected; 
• related or possibly related to participation in the research; and 
• suggest that the research places subjects or others at a greater risk of harm than was 
previously known or recognized.   
If the serious adverse event does not meet all three (3) criteria listed above, the event does not 
have to be promptly reported to the IU IRB.  However, it should be reported at the time of 
continuing review. 
Prompt reporting of unanticipated problems to the IRB is defined as within 5 days from 
becoming aware of the event. 
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16.3.3 Reporting to the IUSCC Data Safety Monitoring Committee: 
Regardless of study sponsorship, the study team must enter all initial and follow-up SAE, 
expedited, and noncompliance reports into OnCore® for review by the DSMC chair and/or 
coordinator. Expedited reports may include IRB Prompt Report Forms, AdEERS reports, 
MedWatch, and additional SAE forms as required by the sponsor. When follow-up information 
is received, a follow-up report should also be created in OnCore®. This DSMC reporting 
requirement is in addition to any other regulatory bodies to be notified (i.e. IRB, FDA, 
pharmaceutical company, etc.). The DSMC chair and/or coordinator will review all SAE, 
expedited, and noncompliance reports monthly. 
16.3.4 Reporting to OnTarget, LLC:  
On Target, LLC will be notified of any serious adverse events (SAEs) that occur and are felt to 
be due to the investigational drug by the investigators. On Target will be notified on the same 
schedule as IRB reporting (within 5 business days from becoming aware of the event).  
Notify Timothy Biro, COO, On Target Laboratories at (216) 533-3082 and email: TBiro 
@ontargetlabs.com, and Ray Lamy, Regulatory Consultant, (480) 620-8897 and email: 
Arciel.llc@cox.net 
17 PATIENT CONSENT AND PEER JUDGEMENT 
The protocol and informed consent form for this study must be approved in writing by the 
appropriate IRB prior to any patient being registered on this study.   
Changes to the protocol, as well as a change of principal investigator, must also be approved by 
the Board.  Records of the Institutional Review Board review and approval of all documents 
pertaining to this study must be kept on file by the investigator and are subject to inspection at any 
time during the study.  Periodic status reports must be submitted to the Institutional Review Board 
at least yearly, as well as notification of completion of the study and a final report within 3 months 
of study completion or termination.   
The study will be conducted in compliance with ICH guidelines and with all applicable federal 
(including 21 CFR parts 56 & 50), state or local laws. 
 
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18 REFERENCES 
 Berdjis N, Hakenberg OW, Zastrow S, Oehlschlager S, Novotny V, Wirth MP. Impact of 
resection margin status after nephron-sparing surgery for renal cell carcinoma. 
BJU international. Jun 2006;97(6):1208-10. 
 Blom JH, van Poppel H, Maréchal JM, Jacqmin D, Schröder FH, de Prijck L, Sylvester R; 
EORTC Genitourinary Tract Cancer Group. Radical nephrectomy with and without lymph-
node dissection: final results of European Organization for Research and Treatment of 
Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol. 2009 Jan;55(1):28-34. 
 Blute ML, Leibovich BC, Cheville JC, Lohse CM, Zincke H. A protocol for performing 
extended lymph node dissection using primary tumor pathological features for patients 
treated with radical nephrectomy for clear cell renal cell carcinoma. The Journal of urology. 
Aug 2004;172(2):465-9. 
 Crispen PL, Boorjian SA, Lohse CM, Leibovich BC, Kwon ED. Predicting disease 
progression after nephrectomy for localized renal cell carcinoma: the utility of prognostic 
models and molecular biomarkers. Cancer. Aug 1 2008;113(3):450-60. 
 Delacroix SE, Jr., Chapin BF, Chen JJ, et al. Can a durable disease-free survival be achieved 
with surgical resection in patients with pathological node positive renal cell carcinoma? The 
Journal of urology. Oct 2011;186(4):1236-41. 
 Fisher RE, Siegel BA, Edell SL, et al. Exploratory study of 99mTc-EC20 imaging for 
identifying patients with folate receptor-positive solid tumors. Journal of nuclear medicine: 
official publication, Society of Nuclear Medicine. Jun 2008;49(6):899-906. 
 Jemal A, Ward E, Thun M. Declining death rates reflect progress against cancer. PloS one. 
2010;5(3):e9584. 
 Kamel MH, Moore PC, Bissada NK, Heshmat SM. Potential years of life lost due to 
urogenital cancer in the United States: trends from 1972 to 2006 based on data from the 
SEER database. The Journal of urology. Mar 2012;187(3):868-71. 
 Kane CJ, Mallin K, Ritchey J, Cooperberg MR, Carroll PR. Renal cell cancer stage 
migration: analysis of the National Cancer Data Base. Cancer. Jul 1 2008;113(1):78-83. 
 Lane BR, Russo P, Uzzo RG, et al. Comparison of cold and warm ischemia during partial 
nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in 
determining ultimate renal function. The Journal of urology. Feb 2011;185(2):421-7. 
 Minervini A, di Cristofano C, Lapini A, et al. Histopathologic analysis of peritumoral 
pseudocapsule and surgical margin status after tumor enucleation for renal cell carcinoma. 
European urology. Jun 2009;55(6):1410-18. 
 Minervini A, Ficarra V, Rocco F, et al. Simple enucleation is equivalent to traditional partial 
nephrectomy for renal cell carcinoma: results of a nonrandomized, retrospective, comparative 
study. The Journal of urology. May 2011;185(5):1604-10. 
 Morshed KM, Ross DM, McMartin KE. Folate transport proteins mediate the bidirectional 
transport of 5-methyltetrahydrofolate in cultured human proximal tubule cells. The Journal of 
nutrition. Jun 1997;127(6):1137-47. 
 Naumann RW, Coleman RL. Management strategies for recurrent platinum-resistant ovarian 
cancer. Drugs. Jul 30 2011;71(11):1397-412. 
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 Palapattu GS, MD, Kristo B, Rajfer J. MD Paraneoplastic Syndromes in Urologic 
Malignancy: The Many Faces of Renal Cell Carcinoma. Rev Urol. 2002 Fall; 4(4): 163–170. 
 Parker N, Turk MJ, Westrick E, Lewis JD, Low PS, Leamon CP. Folate receptor expression 
in carcinomas and normal tissues determined by a quantitative radioligand binding assay. 
Analytical biochemistry. Mar 15 2005;338(2):284-93. 
 Sega EI, Low PS. Tumor detection using folate receptor-targeted imaging agents. Cancer 
metastasis reviews. Dec 2008;27(4):655-64. 
 Simmons MN, Fergany AF, Campbell SC. Effect of parenchymal volume preservation on 
kidney function after partial nephrectomy. The Journal of urology. Aug 2011;186(2):405-10. 
 Tan HJ1, Norton EC, Ye Z, Hafez KS, Gore JL, Miller DC. Long-term survival following 
partial vs radical nephrectomy among older patients with early-stage kidney cancer. JAMA. 
2012 Apr 18;307(15):1629-35. doi: 10.1001/jama.2012.475. 
 van Dam GM, Themelis G, Crane LM, et al. Intraoperative tumor-specific fluorescence 
imaging in ovarian cancer by folate receptor-alpha targeting: first in-human results. Nature 
medicine. Oct  2011;17(10):1315-9. 
 Yu HY, Hevelone ND, Lipsitz SR, Kowalczyk KJ, Hu JC. Use, costs and comparative 
effectiveness of robotic assisted, laparoscopic and open urological surgery. The Journal of 
urology. Apr 2012;187(4):1392-8. 
 
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19 APPENDICES 
19.1 Appendix A 
Assessments 
19.1.1 Partial nephrectomy 
Intraoperative surgeon assessment tool  
Primary surgeon questionnaire: fill out immediately following completion of case. 
1. What camera was used during the case? 
a. da Vinci® Fluorescence Imaging Vision System 
b. Visionsense VSiii 3DHD 
2. At what time was the fluorescent camera first used during the case? 
a. ________________________ 
3. List all organs or structures with fluorescence: 
a. __________________________________________________________________ 
4. Does the tumor show fluorescence? 
a. Very bright fluorescence 
b. Bright fluorescence 
c. Mild fluorescence 
d. Minimal fluorescence 
e. No fluorescence 
5. Does the normal kidney surrounding the tumor show fluorescence? 
a. Very bright fluorescence 
b. Bright fluorescence 
c. Mild fluorescence 
d. Minimal fluorescence 
e. No fluorescence 
6. Compare fluorescence between tumor and kidney: 
a. Tumor is a lot more than the kidney 
b. Tumor is more than the kidney 
c. Tumor is the same as the kidney 
d. Tumor is less than the kidney 
e. Tumor is a lot less than the kidney 
 
 
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7. Does fluorescence aid in locating the renal tumor? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
8. Does fluorescence help resect the tumor? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
9. Does fluorescence help to identify the border or margin of the tumor during resection? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
10. If commercially available would you use this fluorescent product for partial 
nephrectomies? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, most likely not 
e. No, for sure not 
11. Based on white light examination after tumor removal, are there any visible changes to 
organs (erythema or pigment change)? 
a. Yes, explain________________________________________________ 
b. No 
12. Based on white light examination after tumor removal are there any visible changes to 
skin (erythema or pigment darkening)? 
a. Yes, explain________________________________________________ 
b. No 
 
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Blinded surgeon assessment of intraoperative photos 
To be completed by surgeons not involved in case 
1. Photographs taken with and without fluorescent imaging just inside trocar showing hemi-
abdomen: Gerotas, colon, and liver (right); colon, spleen, stomach (left). 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor. 
2. Photographs with and without fluorescent imaging taken after Gerotas removed showing 
tumor and surrounding normal parenchyma. 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor. 
3. Photographs with and without fluorescent imaging taken during resection of tumor. 
a. Place “X” over any fluorescing regions 
b. Place “O” on white light images over tumor areas 
4. Photographs with and without fluorescent imaging taken in tumor fossa after tumor 
removal. 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor. 
 
 
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Ex-vivo assessment of removed tumor 
Primary surgeon to complete on back table immediately following case.  All images are in digital full 
color. 
1. What camera was used for ex-vivo assessment? 
a. da Vinci® Fluorescence Imaging Vision System 
b. Visionsense VSiii 3DHD 
2. Gross fluorescent images of specimen 90° from each other by rotating about central axis.  
Also, upper and lower pole images (6 faces of specimen). 
3. Does the tumor show fluorescence? 
a. Very bright fluorescence 
b. Bright fluorescence 
c. Mild fluorescence 
d. Minimal fluorescence 
e. No fluorescence 
4. 5mm slices through specimen with both fluorescent and white light image of each slice.  
Calibration measurement in photo. 
5. At least 1 representative sample will be sent of primary tumor for FR-α assessment 
 
 
 
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19.1.2 Radical nephrectomy  
Intraoperative surgeon assessment tool  
Primary surgeon questionnaire: fill out immediately following completion of case. 
1. What camera was used during the case? 
a. da Vinci® Fluorescence Imaging Vision System 
b. Visionsense VSiii 3DHD 
c. SPY Elite 
2. At what time was the fluorescent camera first used during the case? 
a. ________________________ 
3. List all organs or structures with fluorescence: 
a. __________________________________________________________________ 
4. Does the tumor show fluorescence? 
a. Very bright fluorescence 
b. Bright fluorescence 
c. Mild fluorescence 
d. Minimal fluorescence 
e. No fluorescence 
5. Does fluorescence aid in locating the lymph nodes or metastasis? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
6. Does fluorescence help with this patient’s radical nephrectomy? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
7. Does fluorescence help to identify the border or margin of the tumor during radical 
nephrectomy? 
a. Yes, a lot 
b. Yes, somewhat 
c. Not sure 
d. No, somewhat worse than without fluorescence 
e. No, a lot worse than without fluorescence 
 
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8. Based on white light examination after tumor removal, are there any visible changes to 
organs (erythema or pigment change)? 
a. Yes, explain________________________________________________ 
b. No 
9. Based on white light examination after tumor removal are there any visible changes to 
skin (erythema or pigment darkening)? 
a. Yes, explain________________________________________________ 
b. No 
 
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Blinded surgeon assessment of intraoperative photos 
To be completed by surgeons not involved in case 
1. Photographs taken with and without fluorescent imaging just inside trocar showing hemi-
abdomen: Gerotas, colon, and liver (right); colon, spleen, stomach (left). 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor or lymph node. 
2. Photographs with and without fluorescent imaging taken after exposure has been 
obtained to the nodal areas or sites of metastasis 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor or lymph node. 
3. Photographs with and without fluorescent imaging taken during resection of tumor. 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor or lymph node. 
4. Photographs with and without fluorescent imaging taken in tumor fossa after tumor 
removal. 
a. Place “X” over any fluorescing regions and draw outline of each fluorescing area 
b. Place “O” on white light images over tumor areas and draw outline of suspected 
tumor or lymph node. 
 
 
 
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Ex-vivo assessment of removed nodes/metastasis 
Primary surgeon to complete on back table immediately following case.  All images are in digital full 
color. 
1. What camera was used during ex-vivo assessment? 
a. da Vinci® Fluorescence Imaging Vision System 
b. Visionsense VSiii 3DHD 
c. SPY Elite 
2. Gross fluorescent images of each enlarged lymph node or metastasis removed 
3. Does the tumor show fluorescence? 
a. Very bright fluorescence 
b. Bright fluorescence 
c. Mild fluorescence 
d. Minimal fluorescence 
e. No fluorescence 
4. 5mm slices through specimen (or bilvalve if < 2cm) with both fluorescent and white light 
image of each slice.  Calibration measurement in photo. 
5. At least 1 representative sample will be sent of primary tumor for FR-α assessment 
 
 
 
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19.2 Appendix B 
Pathology Sample Procedures 
Immunohistochemical procedures: 
Tissue Processing: Tissues were fixed overnight at room temperature in either 10% NBF after which they 
were transferred through graded concentrations of alcohol to xylene inside a Leica Automated Vacuum 
Tissue Processor.  They were embedded in paraffin before being sliced into five micron thick sections, 
mounted onto positively charged slides, baked at 60 C, and then were cut and stained for routine H&E. 
Immunostaining:  
The slides were then deparaffinized in xylene and rehydrated through graded alcohols to water.  Antigen 
retrieval was performed by immersing the slides in Target Retrieval Solution (DAKO) for 20 min. @ 90 
degrees C. (in a water bath), cooling at room temperature for 10 min., washing in water and then 
proceeding with immunostaining.  All subsequent staining steps were performed on the Dako 
Immunostainer; incubations were done at room temperature and Tris buffered saline plus 0.05% Tween 
20, pH 7.4 (TBS - Dako Corp.) was used for all washes and diluents.  Thorough washing was performed 
after each incubation.  Slides were blocked with protein blocking solution (Dako) for 45 min.; after 
washing, 5 μg/ml of the primary antibody, Folate Receptor alpha (Biocare) was added to the slides and 
incubated 30 min to 45 minutes at room temperature.  Following washing in TBST, visual detection was 
performed with the Envision Flex Polymer link, and DAB chromogen (DAKO).  The slides were washed, 
coverslipped and examined using brightfield microscopy. Control sections were treated with an isotype 
control using the same concentration as primary antibodies to verify the staining specificity. 
Whole Slide Digital Imaging:   
The Aperio whole slide digital imaging system was used for imaging.  The Aperio Scan Scope CS system 
was used (360 Park Center Drive, Vista, CA 92081).  The system imaged all slides at 20x.  The scan time 
ranged from 1 ½ minutes to a maximum time of 2.25 minutes.  The whole images were housed and 
stored in their Spectrum software system and images were shot from the whole slides. 
Computer-assisted morphometric analysis of digital images will be done using the Aperio software that 
came with the Aperio Imaging system. (The positive pixel algorithm which is the only FDA approved 
algorithm for clinical trials). 
Automatic Image Quantitation:  
The Positive Pixel Count algorithm was used to quantify the amount of a specific stain present in a 
scanned slide image. The Positive Pixel Algorithm was altered with a hue value of 0.62, hue width of 
0.40, and color saturation threshold of 0.005. A spectrum of color (range of hues and saturation) and 
intensity (weak, positive, and strong) were masked and evaluated. The algorithm counted the number 
and intensity‐sum in each intensity range, along with three additional quantities: average intensity, ratio 
of strong/total number, and average intensity of weak positive pixels. Only staining classified as 
“positive” or “strong positive” was used to calculate positivity; regions classified as “weak positive” were 
mostly cytoplasmic and background staining, and were not counted. The algorithm had a set of default 
input parameters when first selected—these inputs have been pre‐configured for Brown color 
quantification in the three intensity ranges (220‐175, 175‐100, and 100‐0). Pixels which were stained, 
but did not fall into the positive‐color specification, were considered negative stained pixels—these 
pixels were counted as well, so that the fraction of positive to total stained pixels could be determined. 
The ratio of the ‘Positive’ and ‘Strong Positive’ to the total number of pixels provided the positivity 
percentage for each sample. The algorithm was applied to an image using ImageScope. This program 
allows for the selection of an image Region of Analysis and the specification of input parameters. After 
this is completed, the algorithm can be applied and the results can be viewed.  
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19.3 Appendix C 
Surgical Reporting Schematics 
 
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19.4 Appendix D 
da Vinci® Fluorescence Imaging Vision System 
Table of Contents 
(a) Prior Investigations with the Device ....................................................................................... 51 
(b) Methods, Facilities, and Controls ............................................ Error! Bookmark not defined. 
(1) Manufacture ...................................................................................................................... 52 
(2) Processing, Packaging, and Storage................................... Error! Bookmark not defined. 
(3) Installation......................................................................................................................... 53 
(4) Operation........................................................................................................................... 53 
(c) Sample Agreement .................................................................................................................. 54 
(d) Certification of Signed Agreement ......................................................................................... 54 
(e) Institutional Review Boards .................................................................................................... 54 
(f) Institutions............................................................................................................................... 54 
(g) Sale of Equipment ................................................................................................................... 55 
(h) Environmental Assessment ..................................................................................................... 55 
(i) Labeling for the Device .......................................................................................................... 55 
(j) Informed Consent Form .......................................................................................................... 55 
(k) Other Information on the da Vinci® Fluorescence Imaging Vision System ........................... 56 
(l) References ............................................................................................................................... 59 
 
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19.4.1 Prior Investigations with the Device 
This is the first clinical trial in the United States, to employ the da Vinci® Fluorescence Imaging 
Vision System for the intraoperative visualization of renal cell carcinoma labeled with OTL38.  
The critical operational features in a fluorescence camera system include a light source capable 
of providing consistent and even illumination to the surgical field, appropriate excitation and 
emission filters in the light path for OTL38 fluorescence, image collection hardware and 
software, and a system that does not impede the surgeon or compromise the sterility of the 
surgical field. 
There are many potential designs for a camera system intended to visualize -labeled ligands like 
OTL38 in situ. The critical design features in terms of efficacy are: 
• proper wavelength of excitation 
• detection of proper wavelength of emission 
• limiting the detection of autofluorescence or artifacts 
• providing enough illumination to excite the molecule 
• avoiding photobleaching 
• appropriate size of area of illumination 
The critical features in terms of safety are: 
• avoiding phototoxicity to patient or staff 
• limiting the risk of burns 
• limiting exposure to potentially damaging illumination 
The potential efficacy between an experimental system as was used in a study by van Dam et al 
(2011) or an FDA-cleared system is determined by critical design features.  In addition, the 
commercial system, such as the da Vinci® Fluorescence Imaging Vision System, will provide 
greater consistency across sites. The OTL38 dye will be detected in the near infrared spectrum 
with the da Vinci® Fluorescence Imaging Vision System. Autofluorescence is less of a problem 
with a near infrared dye (such as incorporated in OTL38), than with a dye that fluoresces in the 
visible light range (such as fluorescein). Autofluorescence can be related to at least three factors. 
One is intracellular components that appear as bright objects, although rarely the same shade or 
brightness with OTL38. These appear to increase with aging in many species. A second factor is 
extraneous wavelength light, which can illuminate tissue and obscure fluorescein fluorescence - 
this is controlled for with barrier filters; use of a near infrared dye, such as the OTL38 dye, 
decreases the likelihood of extraneous wavelength light, given the OTL38 dye excites at 
wavelengths higher than the visible light range. A third factor is an edge or reflection effect, in 
which edges or variations in tissue become highlighted. This autofluorescence effect disappears 
as the angle of illumination is changed; the OTL38 dye fluorescence will not change. 
The human eye is far superior to any camera system in capturing light and resolving an image. 
This is evident to anyone familiar with low-light photography where the camera must be held 
firmly for even a half-second to many seconds to capture what the eye resolves immediately. In 
fluorescence microscopy or photography, the amount of light is further diminished by the use of 
excitation and emission filters. Thus, the camera system may take considerably longer to record 
labeled tumors than does the surgeon. To enhance the capabilities of the camera system, a 
number of hardware and software integrations are made in the system, optimizing image capture 
and enhancement.  
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The deciding factors in choosing a camera system are related to safety, efficacy, and the 
manufacturer's ability to supply the appropriately tailored system. There are a number of 
variables, some biological, that affect efficacy. After an initial dose of intravenous OTL38, the 
compound will be widely dispersed in the body. Following a period of washout, only regions 
with a high folate receptor density are expected to retain the label. There is no predetermined 
critical saturation point that needs to be reached to make a tumor visible, and a lower 
concentration of labeling can be compensated for with a longer time of illumination and image 
capture. An excess of labeling can lead to decreased fluorescence through quenching, whereby 
neighboring emitted photons interfere with each other. This quenching would diminish over time 
as the concentration of label continued to decrease. The presence of labeling on a suspected 
tumor mass will not be the determining factor in whether the surgeon removes the mass or not in 
this study. The imaging is an adjunct to the surgeon's usual procedures of visualization, 
palpation, and experience. 
A critical safety feature of the system is avoiding phototoxicity to the surgical area, surrounding 
tissues, or retinal tissues in patient or staff. Tissue damage can result either from exposure to 
high-intensity light or to heat generated by a light source. Injury to the surgical area is unlikely as 
the light is restricted by a barrier filter and thus contains only a fraction of the light energy 
released from the source. Both the light energy and the heat produced by this system are unlikely 
to cause tissue damage (Appendix D & Appendix E). A laser is present in the light source, and 
the IEC 60825-1:2007 standard for laser safety is applied to the light engine. This standard 
provides exposure limits that apply to any light source. For skin, in the wavelength region from 
700-800 nm, the MPE (maximal permissible exposure) for skin tissue is set at 200 mW/cm2. The 
duration for the exposure taken in the worst case situation is longer than 1000 seconds. The 
maximum heat produced by any component in the light path is less than 42 °C. Temperatures 
less than 42 °C are considered harmless by the European Medical Device Directive 93/42/EEC. 
The da Vinci® Fluorescence Imaging Vision System was built to avoid extraneous light release 
and thus prevent accidental exposure to light. 
19.4.2 Manufacture 
The da Vinci® Fluorescence Imaging Vision System is manufactured by Intuitive Surgical, Inc.  
It includes the following components:  
• 
An illuminator  capable of providing visible / NIR fluorescence illumination / excitation 
via a flexible light guide cable, and the image processing required to generate 
simultaneous, real-time HD video and fluorescence images  
• 
One flexible light guide cable  
• 
A stereoscopic camera for visible / NIR fluorescence imaging.  
• 
A surgical laparoscope optimized for visible / NIR fluorescence illumination and imaging  
The da Vinci® Fluorescence Imaging Vision System is a component of the da Vinci® Surgical 
System.  As such, the System includes:  
• 
Medical grade System Vision Cart which includes a Medical Grade HD Video Monitor  
• 
Medical grade Surgeon Console for teleoperation of the Surgical System 
• 
Medical grade Patient Side Cart, whose arms hold both the teleoperated laparoscopic 
instruments as well as the camera / laparoscope assembly. 
The da Vinci® Fluorescence Imaging Vision System is CE marked and has received numerous 
FDA 510K clearances for use in minimally invasive surgery (K124031, K101077, K141077)   
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19.4.3 Module Testing 
Modules of the da Vinci® Fluorescence Imaging Vision System system are tested before final 
system assembly. The individual components are tested as per the manufacturing process. These 
tests include functional and performance tests as well as any proscribed electro-medical safety 
tests.  All components bear the CE mark. The 3rd party medical grade accessories such as drapes 
are stand-alone certified medical device components and are not further tested. 
19.4.4 System Testing 
The da Vinci® Fluorescence Imaging Vision System is tested in a system configuration during 
manufacturing.  Additional system level testing is carried out during standard compliance testing 
in product development. 
19.4.5 Packaging and Unpacking 
Systems components are packaged separately and are combined when ordered. Upon delivery to 
the participating medical center, the designated representative will sign for the equipment and 
arrange for its secure storage. 
Intuitive Surgical certifies that: 
(a) The mutual compatibility of the components and accessories that comprise the da Vinci® 
Fluorescence Imaging Vision System has been verified; 
(b) The information for users supplied with the da Vinci® Fluorescence Imaging Vision 
System incorporates relevant instructions from the manufacturer; and 
(c) The appropriate methods of internal control and inspection have been applied. 
19.4.6 Installation 
Upon delivery to the participating medical center, the da Vinci® Surgical System will be 
assembled and tested as per operating instructions. The unit will be assembled, tested for 
operation, and kept as a complete unit. 
19.4.7 Operation 
The da Vinci® Fluorescence Imaging Vision System is used to image OTL38 as follows:  
OTL38 is administered 2 to 3 hours prior to scheduled surgery. The agent is rapidly distributed 
after IV administration and also rapidly eliminated from the circulation. Tissues containing high 
concentrations of folate receptors sequester the agent. 
When illuminated by the NIR excitation light produced by the da Vinci® Fluorescence Imaging 
Vision System, the tissues containing OTL38 continue to fluoresce while the surrounding tissues 
become dark. The agent was shown to preferentially label folate-receptor-positive tumors in 
animal models. Tumors that contain folate receptors will bind OTL38, and the da Vinci® 
Fluorescence Imaging Vision System will cause the tumors to appear green in the augmented 
image displayed in the Surgeon Console and on the video monitor. In animal models, tumor-
specific fluorescence was shown to last at least 8 hours after administration allowing for post-
surgical tumor imaging. Although normal kidney proximal tubule cells contain folate receptors 
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and uptake of OTL38 in the kidneys is possible, the fluorescence signal in the kidneys is 
expected to be significantly lower than the tumor tissues (Ross 1994). 
Investigators will employ the device in their procedures as outlined. Once the patient has 
undergone surgical preparation for a partial nephrectomy and the laparoscope has been inserted 
into the abdomen, images of the surgical area will be captured using both a fluorescence and 
white light examination prior to tumor excision. The images will be evaluated to determine the 
extent of tumor involvement and confirm these assessments with normal visual examinations. 
Surgery will be performed as per usual protocol/procedure, after which a follow-up image of the 
surgical field will be captured using fluorescence imaging. The remaining fluorescent tissues 
will be evaluated for possible tumor involvement and the surgical procedure will be finished as 
indicated. 
19.4.8 Device Agreement 
The da Vinci® Fluorescence Imaging Vision System is supplied for the purposes of a clinical 
investigation of OTL38 for intraoperative of renal cancer. While it is an FDA-approved device 
when used in the indications for which is it approved, when used with OTL38 it should be 
considered an investigational device not intended for the diagnosis or treatment of human 
disease.  This device is only intended for use in conjunction with OTL38 in the context of the 
clinical trial. By my signature below, I certify that I understand this agreement and will comply 
with these stipulations. 
Signature of Principal Investigator 
 
Name of Principal Investigator 
 
Investigative Site 
 
19.4.9 Certification of Signed Agreement 
The Sponsor hereby certifies that the da Vinci® Fluorescence Imaging Vision System will only 
be provided to qualified investigators in conjunction with the clinical protocol entitled, 
“Intraoperative folate targeted fluorescence in renal cell carcinoma.”  
19.4.10 Institutional Review Boards 
This instrument will be used as part of a controlled clinical trial. The IRB will be identified on 
Form FDA 1572 for each investigator engaged. 
19.4.11 Institutions 
Each institution to be used in the clinical trial will be identified on Form FDA 1572.  
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19.4.12 Sale of Equipment 
The system will not be sold to centers but will be provided as part of the clinical trial. 
19.4.13 Environmental Assessment 
The Sponsor applies for categorical exemption from an Environmental Assessment based on 
21 CFR 25.31. 
19.4.14 Labeling for the Device 
The da Vinci® Fluorescence Imaging Vision System contains labels as described in the 
Operator’s Manual. The Sponsor will attach a label on each extended system cart identifying the 
system as: 
 
19.4.15 Operator’s Manual 
The instructions for use of the da Vinci® Fluorescence Imaging Vision System are contained in 
the Site Manual, Instructions for Use document. The Operator’s Manual includes the following 
chapters and appendices: 
• 
Health and Safety Compliance 
• 
Unpacking and Set-up  
• 
Controls and Indicators 
• 
Operation 
• 
Cleaning and Sterilizing 
• 
Troubleshooting 
19.4.16 Informed Consent Form 
The informed consent form will be the same as that for entry into the clinical study. 
da Vinci® Fluorescence Imaging Vision System  
FOR INVESTIGATIONAL USE ONLY 
This device is only to be used by qualified investigators in conjunction with the clinical protocol 
entitled, “Intraoperative folate targeted fluorescence in renal cell carcinoma” 
Sponsor: IU 
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19.4.17 Other Information for da Vinci® Fluorescence Imaging Vision System  
19.4.17.1 Specifications  
  
Table-1  
VPI Specifications 
Feature 
Specification 
Light Sources 
Spectrum 
400 – 700 nm 
Near infrared (NIR) 
Type 
Light emitting diode 
array 
NIR laser diode 
Inputs/Outputs 
Video output signals 
HD-SDI, DVI, S-Video 
HD format 
1080i 
Picture elements 
1920 x 1080  
Service port I/O 
Ethernet (IEEE 802.3) 
Operator 
Controls 
Power on/off 
Front panel switch 
Standby  
Front panel button 
White balance 
Camera Head  
White light/fluorescence 
mode 
Surgeon Console / Vision Cart Button 
Video display option 
Vision Cart Button 
Operating 
Environment 
Operating temperature 
+10° to +30°C 
Relative humidity 
10 to 85% non-condensing 
Storage and 
Transport 
Environment 
Humidity range (storage) 
10 to 85% 
Temperature range 
(storage) 
-10° to +55°C 
Humidity range 
(transport) 
5 to 95% 
Physical 
Dimensions  
W 394 mm × H 140 mm × D 432 mm 
Weight 
13 kg 
Electrical Power 
Voltage 
100/120/230 VAC 
Power frequency 
50/60 Hz 
Power consumption 
400 VA 
 
 
 
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Table-2 
Camera Head Specifications 
Feature 
Specification 
Optical 
Image sensors 
CCD HD sensor assembly 
HD format 
1080i 
Aspect ratio 
16:9 
 
Dimensions  
79 x 90 x 194  / 46 x 130 x 116  (mm ) 
Physical 
Weight 
600 g  
Cable length 
5.75 m  
Environment 
Operating temperature 
+10° to 30°C 
Relative humidity 
10 to 85% non-condensing 
Storage temperature 
-10° to +55°C 
Sterilization 
Sterile Drape 
Table-3 
12 mm Laparoscope Specifications 
Feature 
Specification 
Optical 
Viewing angle 
0° and 30° 
Field of view 
60° 
Resolution 
HD compatible 
Transmission spectrum 
Visible + NIR 
Physical 
Outer diameter  
12 mm 
Working length 
387 mm 
Environment 
Operating temperature 
+10° to 30°C 
Storage temperature 
-10° to +55°C 
Sterilization 
Sterrad 
 
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Table-4 
Light Guide Cable Specifications 
Feature 
Specification 
Optical 
Transmission spectrum 
Visible Light and Near-Infrared 
Physical 
Fiber diameter  
~ 5mm  
Length 
~ 5.75m  
Environment 
Operating temperature 
+10° to 30°C 
Storage temperature 
-10° to +55°C 
Table-5 
Equipment Classification  
Feature 
Specification 
Type of protection against electric 
shock 
Class I 
as per IEC 60601-1 
Degree of protection against electric 
shocks 
CF-type 
Degree of protection against moisture 
Ordinary 
Laser class 
Class 3R  
as per IEC 60601-1 
Radio frequency emissions 
Group 1, Class A as per CISPR 11 
Harmonic emissions 
Class A 
as per IEC 61000-3-2 
 
Table-6 
NIR Radiation and Source Characteristics 
Feature 
Specification 
Apertures for NIR radiation emission 
Laparoscope tip or light guide (if endoscope is 
detached)   
Accessible NIR 
radiation (at the tip 
of the laparoscope) 
Wavelength  
808 ± 4 nm 
Embedded laser 
source 
Classification 
Class 3R, invisible 
 
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19.4.17.2 References 
Ross J, Chaudhuri P, Ratnam M. Differential regulation of folate receptor isoforms in normal 
and malignant tissues in vivo and in established cell lines. Cancer. 1994;73:2432-43. 
van Dam GM, Themelius G, Crane LMA, et al. Intraoperative tumor-specific fluorescence 
imaging in ovarian cancer by folate receptor-α targeting: first in-human results. Nature Med. 
2011;17:1315. 
van Melick RGM, Bakkera D, Meester RJC, Cilia G, Löwik CWGM. DLP® technology's 
pivotal role in O2view's versatile medical projection / illumination device. In: Proc. SPIE, 
Conference title Emerging Digital Micromirror Device Based Systems and Applications II, M.R. 
Douglass and L.J. Hornbeck (eds.), Vol. 7596, Issue 1, 759603 (2010). doi:10.1117/12.846016. 
 
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19.5 Appendix E 
SPY Elite Technical Information 
 
 
 
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19.6 Appendix F 
NCI Common Toxicity Criteria (Version 4.0) 
 
Due to the size of the latest version of the Common Toxicity Criteria, copies of this appendix are 
not included with this protocol document. 
 
An electronic copy is available on the CTEP web site, http://ctep.cancer.gov/reporting/ctc.html 
 
19.7 Appendix G 
Performance Status Scales/Scores 
 
ECOG or Zubrod                              Karnofsky  
                 
 
Lansky 
Score        Activity               Score                Activity                      Score               Activity 
0 
Fully active, able to 
carry on all pre-
disease performance 
without restriction. 
100 
 
 
90 
Normal, no complaints, no 
evidence of disease. 
 
Able to carry on normal 
activity; minor signs or 
symptoms of disease. 
 
100 
 
 
90 
Fully active, normal. 
 
 
Minor restrictions in physically 
strenuous activity. 
1 
Restricted in 
physically strenuous 
activity but 
ambulatory and able 
to carry out work of 
a light or sedentary 
nature, e.g., light 
housework, office 
work. 
80 
 
 
 
 
70 
Normal activity with effort; 
some signs or symptoms of 
disease. 
 
Cares for self, unable to carry 
on normal activity or do active 
work. 
80 
 
 
 
 
70 
Active, but tires more quickly. 
 
 
 
Both greater restriction of and less 
time spent in play activity. 
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2 
Ambulatory and 
capable of all 
selfcare but unable 
to carry out any 
work activities.  Up 
and about more than 
50% of waking 
hours. 
 
 
60 
 
 
 
50 
Requires occasional 
assistance, but is able to care 
for most of his/her needs. 
 
Requires considerable 
assistance and frequent 
medical care. 
 
 
60 
 
 
 
50 
Up and around, but minimal active 
play; keeps busy with quieter 
activities. 
 
 
Gets dressed, but lies around much 
of the day; no active play; able to 
participate in all quiet play and 
activities. 
3 
Capable of only 
limited selfcare, 
confined to bed or 
chair more than 50% 
of waking hours. 
40 
 
 
 
30 
Disabled, requires special care 
and assistance. 
 
Severely disabled, 
hospitalization indicated.  
Death not imminent. 
40 
 
 
 
30 
Mostly in bed; participates in quiet 
activities. 
 
In bed; needs assistance even for 
quiet play. 
4 
Completely 
disabled.  Cannot 
carry on any 
selfcare. Totally 
confined to bed or 
chair. 
20 
 
 
10 
Very sick, hospitalization 
indicated.  Death not 
imminent. 
Moribund, fatal processes 
progressing rapidly. 
20 
 
 
10 
 
Often sleeping; play entirely 
limited to very passive activities. 
No play; does not get out of bed. 
 
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19.8 Appendix H 
DSMC Meeting Minutes Template 
 
 
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19.9 Appendix I 
OTL38 Pharmacy Dose Preparation Manual 
 
Please reference the Pharmacy Dose Preparation Manual for this study which can be made 
available upon request. 
 
 
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