Multi-center, Open-labeled, Non-randomized Study to Evaluate the Acute Technical Performance and Safety Profile of the VORTX Rx® for Ablation of Primary and Metastatic Liver Tumors (Theresa Study)
Phase: NA
Conditions: Carcinoma, Hepatocellular, Liver Metastases
Sponsor: HistoSonics, Inc.

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INVESTIGATIONAL PLAN 
“MULTI-CENTER, OPEN-LABELED, NON-
RANDOMIZED STUDY TO EVALUATE THE 
TECHNICAL PERFORMANCE AND SAFETY 
PROFILE OF THE VORTX Rx® FOR ABLATION OF 
PRIMARY AND METASTATIC LIVER TUMORS 
(Theresa Study)” 
 
Protocol Number: 03.CP.0.3 
Protocol version: 3.0, 26 September 2018 
 
Sponsor: HistoSonics, Inc. 
 
Coordinating investigator: 
Dr. Joan Vidal-Jove 
Comprehensive Tumor Center Barcelona, S.L. 
Institut Khuab 
Pla. Mons, 1 – 08023 – Barcelona (Spain) 
 
Confidentiality 
The information contained in this document is the property of the sponsor and is therefore provided to 
you confidentially for review by yourself, your research team, the ethics committee and the competent 
authorities. The information contained herein will not be disclosed to others without prior written 
authorization from the sponsor, except to the extent necessary to obtain informed consent from those 
persons who participate in the study 

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TABLE OF CONTENTS 
TABLE OF CONTENTS .................................................................................................................................... 2 
1 
PROTOCOL SUMMARY ............................................................................................................................ 5 
1.1 
STUDY TITLE .................................................................................................................................................. 5 
1.2 
PROTOCOL CODE ......................................................................................................................................... 5 
1.3 
PROTOCOL VERSION .................................................................................................................................... 5 
1.4 
SPONSOR ...................................................................................................................................................... 5 
1.5 
INVESTIGATORS AND SITES .......................................................................................................................... 5 
1.6 
MONITOR LOCAL CONTACT ......................................................................................................................... 6 
1.7 
CLINICAL RESEARCH ETHICS COMMITTEE................................................................................................. 6 
1.8 
DISEASE UNDER STUDY ............................................................................................................................... 6 
1.9 
PRIMARY OBJECTIVE .................................................................................................................................... 6 
1.10 
PRIMARY ENDPOINT ................................................................................................................................ 6 
1.11 
SECONDARY OBJECTIVES ...................................................................................................................... 6 
1.12 
STUDY DESIGN ......................................................................................................................................... 7 
1.13 
STUDY MEDICAL DEVICE ......................................................................................................................... 8 
1.14 
STUDY POPULATION ................................................................................................................................ 9 
1.15 
STUDY TIMELINES .................................................................................................................................... 9 
2 
BACKGROUND AND STUDY RATIONALE ...................................................................................... 10 
2.1 
LIVER TUMORS ............................................................................................................................................ 10 
2.2 
HISTOTRIPSY - NON-THERMAL; FOCUSED ULTRASOUND ........................................................................ 11 
2.3 
HISTOTRIPSY FOR LIVER TUMORS ............................................................................................................. 12 
2.4 
CLINICAL EXPERIENCE WITH THE VORTX RX® ....................................................................................... 14 
2.4.1 
Benign Prostatic Hyperplasia ...................................................................................................... 14 
2.4.2 
VORTX Rx® for liver tumors ........................................................................................................ 15 
2.5 
STUDY RATIONALE ...................................................................................................................................... 15 
2.6 
RISK-BENEFIT ASSESSMENT ...................................................................................................................... 16 
3 
STUDY OBJECTIVES ............................................................................................................................... 18 
3.1 
PRIMARY OBJECTIVE .................................................................................................................................. 18 
3.2 
SECONDARY OBJECTIVES ......................................................................................................................... 18 
4 
STUDY ENDPOINTS ................................................................................................................................. 19 
4.1 
PRIMARY ENDPOINT ................................................................................................................................... 19 
4.2 
SECONDARY ENDPOINTS ........................................................................................................................... 19 
5 
STUDY DESIGN ......................................................................................................................................... 20 
5.1 
OVERALL STUDY DESIGN ........................................................................................................................... 20 
5.2 
TREATMENT ASSIGNMENT OR RANDOMIZATION ....................................................................................... 23 
5.3 
STUDY POPULATION ................................................................................................................................... 23 
5.3.1 
Inclusion criteria ............................................................................................................................. 23 
5.3.2 
Exclusion criteria ............................................................................................................................ 24 
5.3.3 
Withdrawal criteria ......................................................................................................................... 25 
5.4 
STUDY PERIODS AND DURATION ............................................................................................................... 26 
5.4.1 
Screening (day -60 to day 0) ....................................................................................................... 30 
5.4.2 
Visit 1: Vortx Rx Ablation Procedure ......................................................................................... 34 
5.4.3 
Visit 2: 24 hours Post-Ablation .................................................................................................... 34 
5.4.4 
Visit 3: One week Post-Ablation ................................................................................................. 35 
5.4.5 
Visit 4: One month Post-Ablation ............................................................................................... 36 
5.4.6 
Visit 5: Two months Post-Ablation ............................................................................................. 37 
5.4.7 
End of the study or termination................................................................................................... 38 
6 
ABLATION ................................................................................................................................................... 38 
6.1 
MEDICAL DEVICE ......................................................................................................................................... 38 
6.1.1 
Medical device overview .............................................................................................................. 38 
6.2 
ABLATION PROCEDURE USING THE VORTX RX ........................................................................................ 40 

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6.3 
MEANS OF SUPPLY OF THE MEDICAL DEVICE ........................................................................................... 41 
7 
CONCOMITANT MEDICATIONS........................................................................................................... 41 
7.1 
PERMITTED CONCOMITANT MEDICATIONS ................................................................................................ 41 
7.2 
PROHIBITED CONCOMITANT MEDICATIONS/INTERVENTIONS................................................................... 42 
8 
ASSESSMENTS ......................................................................................................................................... 42 
8.1 
ABLATION ASSESSMENTS .......................................................................................................................... 42 
8.1.1 
Technical Performance assessments ....................................................................................... 43 
8.1.2 
Tumor Progression Assessment................................................................................................ 43 
8.1.3 
Involution of the Ablation Zone ................................................................................................... 43 
8.2 
SAFETY ASSESSMENTS .............................................................................................................................. 43 
8.2.1 
Physical examination .................................................................................................................... 44 
8.2.2 
Vital signs ........................................................................................................................................ 44 
8.2.3 
Height and weight .......................................................................................................................... 44 
8.2.4 
ECOG performance status .......................................................................................................... 44 
8.2.5 
Laboratory evaluations ................................................................................................................. 44 
8.2.6 
Pregnancy test ............................................................................................................................... 45 
8.3 
OTHER ASSESSMENTS ............................................................................................................................... 45 
8.3.1 
Screening purpose ........................................................................................................................ 45 
8.3.2 
Patient Reported Outcome assessment .................................................................................. 46 
9 
SAFETY MONITORING AND REPORTING ....................................................................................... 47 
9.1 
EXPECTED ADVERSE EVENTS .................................................................................................................... 47 
9.2 
SAFETY PLAN .............................................................................................................................................. 47 
9.3 
ADVERSE EVENTS ....................................................................................................................................... 48 
9.3.1 
Definitions ........................................................................................................................................ 48 
9.3.2 
Causality .......................................................................................................................................... 49 
9.3.3 
Severity ............................................................................................................................................ 51 
9.4 
COLLECTING AND REPORTING OF ADVERSE EVENTS .............................................................................. 51 
9.4.1 
Reporting of serious adverse events......................................................................................... 52 
9.5 
DATA AND SAFETY MONITORING BOARD ................................................................................................. 53 
10 
STATISTICAL METHODS AND DATA ANALYSIS .......................................................................... 54 
10.1 
SAMPLE CALCULATION .......................................................................................................................... 54 
10.2 
OVERALL CONSIDERATIONS ................................................................................................................. 54 
10.3 
ANALYSIS SETS ...................................................................................................................................... 55 
10.3.1 Full analysis set .............................................................................................................................. 55 
10.3.2 Safety population ........................................................................................................................... 55 
10.3.3 Technical Performance population ............................................................................................ 55 
10.4 
PATIENT DEMOGRAPHICS/OTHER BASELINE CHARACTERISTICS ....................................................... 55 
10.5 
PRIMARY OBJECTIVE/ENDPOINT .......................................................................................................... 55 
10.6 
SECONDARY OBJECTIVES .................................................................................................................... 55 
11 
ETHICAL CONSIDERATIONS ............................................................................................................... 57 
11.1 
REGULATORY AND ETHICAL COMPLIANCE ........................................................................................... 57 
11.2 
INFORMED CONSENT PROCEDURES .................................................................................................... 57 
11.3 
CONFIDENTIALITY .................................................................................................................................. 58 
12 
PRACTICAL CONSIDERATIONS ......................................................................................................... 58 
12.1 
ARCHIVING ............................................................................................................................................. 58 
12.2 
SOURCE DOCUMENTS ........................................................................................................................... 58 
13 
QUALITY CONTROL ................................................................................................................................ 59 
13.1 
STUDY MONITORING .............................................................................................................................. 59 

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14 
FUNDING ...................................................................................................................................................... 59 
15 
PUBLICATION GUIDELINES ................................................................................................................. 60 
16 
REFERENCES ............................................................................................................................................ 61 
17 
APPENDICES ............................................................................................................................................. 65 
APPENDIX 1. PATIENT INFORMATION SHEET AND INFORMED CONSENT FORM (ICF) ..................................... 65 
APPENDIX 2. NCI-CTCAE (VERSION 4.0) ........................................................................................................ 66 
APPENDIX 3. INTERNATIONAL WORKING GROUP ON IMAGE-GUIDED TUMOR ABLATION GUIDANCE 
DOCUMENT ............................................................................................................................................................ 67 
APPENDIX 4. EORTC QLQ-C30 QUESTIONNAIRE ........................................................................................... 68 
APPENDIX 5. VAS FOR PAIN ASSESSMENT ........................................................................................................ 69 
APPENDIX 6. EASTERN COOPERATIVE ONCOLOGY GROUP PERFORMANCE STATUS (ECOG) ................... 70 
APPENDIX 7. AMERICAN SOCIETY OF ANESTHESIOLOGIST SCORE ................................................................. 71 
 

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1 
PROTOCOL SUMMARY 
1.1 STUDY TITLE 
Multi-center, open-labeled, non-randomized study to evaluate the acute technical performance 
and safety profile of the VORTX Rx® for ablation of primary and metastatic liver tumors 
(Theresa Study). 
1.2 PROTOCOL CODE 
03.CP.0.3 
1.3 PROTOCOL VERSION 
3.0, 26 September 2018 
1.4 SPONSOR  
HistoSonics, Inc 
3526 W Liberty Rd #100, Ann Arbor, MI 48103, United States 
Telephone number: +1 734-929-3074 or +1 775-392-2970 
Sponsor representative:  Michael A. Daniel, VP Clinical / Regulatory Affairs  
E-mail: madaniel@clinregconsult.com   
 
Local Representative / Clinical Research Organization  
Dynamic Science S.L 
C/ Azcona 31. 28028 Madrid Spain 
Telephone number: +34 91 456 11 05 / 648 246 655 
Marta Domínguez de Dios, Clinical Team Leader 
E-mail: m.dominguez@dynasolutions.com 
 
1.5 INVESTIGATORS AND SITES 
Coordinating Investigator: 
Dr. Joan Vidal-Jove 
Comprehensive Tumor Center Barcelona, S.L 
Institut Khuab.  
Plaça Mons, 1, 08023 Barcelona (Spain) 
Telephone number: +34 932 09 59 16 
E-mail address: jvidal@mutuaterrassa.es 
 
See signature page for sponsor and Principal Investigator agreement on the protocol, including compliance 
with ISO 14155, data protection laws, and Declaration of Helsinki.  
 

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Participating investigators and sites: 
This is a multi-center study comprised of three (3) independent centers located in the greater 
metropolitan Barcelona area. The coordinating investigator, Dr. Joan Vidal-Jove, will perform all 
ablation procedures during the study.  
The coordinating investigator, Dr. Vidal-Jove, is an experienced surgical oncologist who leads 
the first High Intensity Focused Ultrasound (HIFU) Unit in Surgical Oncology in Spain, where he 
has performed more than 200 HIFU procedures in the last years for liver, pancreas and other 
solid tumors. 
1.6 MONITOR LOCAL CONTACT 
Dynamic Science S.L. 
C/ Azcona, 31. 
28028 Madrid, Spain. 
Telephone number: +34 91 456 11 05. 
Fax number: +34 91 456 11 26. 
1.7 CLINICAL RESEARCH ETHICS COMMITTEE 
The study will be evaluated by the Ethics Committee for investigation with medicinal products 
(hereinafter CEIm for its initials in Spanish, Comité Ético de la Investigación con medicamentos) 
of Mútua Terrassa University Hospital.  
1.8 DISEASE UNDER STUDY 
The disease under study is liver cancer. Patients with primary hepatocellular carcinoma (HCC) 
and patients with liver metastases from colorectal, breast, lung or pancreatic cancers will be 
included.  
1.9 PRIMARY OBJECTIVE 
The primary objective of the study is to evaluate the acute technical performance of the VORTX 
Rx® medical device for the ablation of primary and metastatic liver tumors.  
1.10 PRIMARY ENDPOINT 
The primary endpoint of the study is acute technical success, consisting of success in treating 
the planned ablation volume (PAV), defined as the ability of the investigational device to create 
an ablation zone per the PAV (a three-dimensional volume defined by the investigator using the 
VORTX Rx® in the planning phase of the software workflow), as measured by multi-dimensional 
imaging and characterized qualitatively in the radiological report 1-day post ablation. The acute 
technical success of up to 3 separate tumor ablations in a single patient will be assessed.   
1.11 SECONDARY OBJECTIVES 
 
Assessment of the safety profile of the VORTX Rx®. 
 
Assessment of local tumor progression by MRI at 1 week, 1 month and 2 months, post-
procedure. 
 
Assessment of the involution of the ablation zone at 1 week, 1 month and 2 months, 
post-procedure.  

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 
Assessment of liver panel.  
 
Immunologic assessment. 
 
Evaluation of quality of life. 
 
Assessment of pain and analgesic requirements after the ablation procedure.  
1.12 STUDY DESIGN 
This is an open-label (no masking), non-randomized, multi-center study comprised of three (3) 
independent centers located in the greater metropolitan Barcelona area.  
The coordinating investigator, Dr. Joan Vidal-Jove, will perform all ablation procedures during 
the study.  
The primary objective of this study is to evaluate the acute technical performance of the VORTX 
Rx® medical device for the ablation of primary and metastatic liver tumors.  
Ablation of the targeted tissue will be evaluated using MRI analysis following a predefined 
imaging protocol to assess acute technical success defined as the ability of the investigational 
device to create an ablation zone per the planned ablation volume (PAV) (a three-dimensional 
volume defined by the investigator using the VORTX Rx in the planning phase of the software 
workflow). CT analysis and ultrasound with or without contrast may be also utilized per 
investigator discretion.  
The pre-specified technical success criteria and imaging protocol greatly reduces the possibility 
of unplanned changes being made based on interim trial findings, reducing operational bias and 
supporting findings of scientific integrity of this study.  
This technical performance study will use the VORTX Rx® device to deliver acoustic energy for 
cavitation-based cellular destruction. The planned ablation duration of the target tumor will be 
60 minutes or less and adjusted intra-procedurally as necessary per investigator discretion. 
Subjects in this study must have an adequate acoustic window in the abdominal space in order 
to be eligible for enrollment. All patients who undergo ablation with the investigational device will 
be treated in a hospital environment under general anesthesia not to exceed four (4) hours.  
Up to three separate ablation sessions will be allowed to be performed in a single patient during 
the study with a minimum of 1 month between sessions. It will be allowed to treat more than one 
tumor in the same session whenever the total volume of the tumors ablated is determined to be 
less than or equal to the volume of a single 3 cm diameter tumor. Each tumor is required to 
meet the criteria defined for a targeted tumor in the study protocol: diameter of less than or 
equal to 3 cm (≤3 cm) and clearly separated from other tumors or other critical areas (i.e. 
located in different segments of the liver).  
Targeted tumors can be retreated upon investigator discretion (i.e. in case that residual tumor is 
detected). Retreatment of a tumor will be performed 1 month after the prior ablation of the 
tumor. 
In all cases, at least a one-month period must have elapsed between the last ablation 
performed and the next ablation session in any individual patient.  
Retreatment of a tumor and ablation of a new tumor are not allowed to be performed in the 
same session. Any required re-treatment will be performed prior to any new treatment in any 
individual patient. Treatment of a new tumor in a new patient will be allowed prior to retreatment 
of a tumor in a previous patient. 
For safety purposes, this study will take a two (2) step approach:  
Step 1: 

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a. The first subject enrolled will be observed and assessed over a 24-hour period and shall 
not have experienced any unexpected serious adverse event attributable to the study 
device.  
b. After completion of Step 1a, the second subject enrolled will be observed and assessed 
over a 24-hour period and shall not have experienced any unexpected serious adverse 
event attributable to the study device.    
Step 2:  
 
Once Step 1a and 1b are complete, the remaining subjects, after meeting all inclusion 
(and no exclusion) criteria may be enrolled and treated on a first-come, first-served 
basis.  
Should the first or second subject experience an unexpected serious adverse event attributable 
to the investigational device, the principal investigator will consult with the Data and Safety 
Monitoring Board (DSMB), his co-investigator(s) and the sponsor and together determine the 
appropriate next course of action regarding study. If after such consultation and review, it is 
determined that the study resume, a third patient will be enrolled and monitored in a similar 
fashion before commencing with successive enrollment.    
An independent DSMB will be used for review of safety data to provide advice to the Sponsor to 
ensure safety, protection and well-being of subjects enrolled in the study. Additional details 
regarding the structure of the DSMB is provided in Section 9.5. 
The study enrollment period is expected to require up to twelve (12) months and the study 
follow-up period per patient will be a minimum of two (2) months with a maximum follow up 
period to be determined by the number of tumors ablated and what is medically appropriate. 
However, it is anticipated that no more than 9 months should be required to complete patient 
follow up, or until the withdrawal of the patient due to any reason, whichever is first. Therefore, 
the total study duration may extend to approximately 21 months.  
The study will consist of: 
 
a screening period (within the 2-month period prior to the ablation procedure) that 
includes a pre-planning visit in which the procedure simulation will be performed using  
the VORTX Rx® medical device to confirm visualization of target tumor and expected 
ablation volume using B-Mode Ultrasound,  
 
the ablation procedure,  
 
four post-ablation study visits: one (1) day, one (1) week and one (1) and two (2) 
months post-ablation. 
This schedule will apply for each tumor ablated (or combinations of tumors ablated in the 
same session) (up to a total of 3 separate ablation sessions) and for retreated tumors. 
1.13 STUDY MEDICAL DEVICE 
Investigational medical device: VORTX Rx® (HistoSonics, Inc., Ann Arbor, MI, USA) 
The HistoSonics VORTX Rx design and proposed intended purpose is for the ablation of soft 
tissue, including liver tumors. This device is for Investigational Purposes Only and will NOT be 
CE Marked. The proposed conformity assessment and rational of the VORTX RX® System is a 
Class IIb, rule 9 device.  It is an active, non-implantable medical device.  The primary mode of 
action is to ablate soft tissue through mechanical focused ultrasound cavitation and is software 
controlling. (Global Medical Device Nomenclature (GMDN - 57873) - therapeutic ultrasound 
systems and associated devices). The system is a portable ultrasound medical device designed 
to ablate soft tissues, including liver tissue, using very low duty cycle ultrasound pulses applied 

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from an ultrasound transducer outside the patient’s body (extracorporeal). Ultrasound imaging is 
used for procedure planning, image-guided targeting, and real-time ablation feed-back while 
under direct physician control. 
The fundamental part of the ultrasonic transducer is the piezoelectric element, which vibrates 
when electricity is applied to it. This produces ultrasonic waves that propagate through tissue.  
By arranging the array of elements into a concave formation, the transducer is capable of 
focusing ultrasonic waves that increase in strength at the focal point. When these waves are 
applied in pulses they create an effect known as “histotripsy,” focused non-thermal ultrasound 
ablation.  
The transducer is aimed at a target, in this case liver tissue. Alternating pressure waves pass 
through the tissue with the negative pressures being low enough to pull gas out of surrounding 
tissues and form bubbles. The collapse of these bubbles and repeated pressure changes ablate 
the targeted tissue. Using this method, the ablation can be precisely controlled. 
1.14 STUDY POPULATION 
Study population: consenting adult patients (aged ≥18 years) with inoperable HCC or patients 
with unresectable liver metastases from colorectal, breast, lung or pancreas cancer, with a 
maximum of 3 targeted tumors of less than or equal to 3 cm (≤3 cm) are candidates for this 
study. The target population for this study will be patients with liver tumors that are not 
candidates for surgical resection and not suitable for other locoregional treatments for any 
reason or have not responded to conventional therapies. Inclusion/exclusion criteria are fully 
described in section 5. 
Number of patients: up to 10 patients will be included in the study.   
1.15 STUDY TIMELINES 
The study is expected to follow the timelines below (subject to changes due to administrative 
processes and study start-up): 
 
Study submission to the CEIm and Spanish Agency of Medicines and Medical Devices 
(AEMPS for its initials in Spanish, Agencia Española de Medicamentos y Productos 
Sanitarios): Q4 2017. 
 
Study approval (CEIm and AEMPS]): Q4 2017. 
 
Inclusion of patients in the study: Q1 2018 – Q1 2019 (12 months) 
 
Follow-up period end: Q2-Q3 2019. 
 
Closure of database: Q4 2019. 
 
Data analysis: Q4 2019. 
 
Final study report: Q1 2020. 

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2 
BACKGROUND AND STUDY RATIONALE 
2.1 LIVER TUMORS 
The liver is a common site for both primary malignancy and metastatic disease. Hepatocellular 
carcinoma (HCC), accounting for 70-90% of cases of primary liver cancer, is the most common 
primary malignancy of the liver. HCC is a major health problem worldwide associated with high 
morbidity and mortality. It is the fifth most common cancer and the second most common cause 
of cancer-related death in the world (1). Its age-adjusted worldwide incidence has been 
estimated at 16 cases per 100,000 people (2) and accounts for >600,000 new cases annually 
worldwide (3-5). In Spain over 3,000 cases are diagnosed every year (14 for every 100,000 men 
and 4 for every 100,000 women). Most cases of HCC are secondary to either viral hepatitis 
infection or cirrhosis. Indeed, HCC is the leading cause of death among patients with liver 
cirrhosis (6).  
Hepatic metastases are present in approximately 40% to 50% of adult patients with extra-
hepatic primary tumors (7). The liver is the most common site of distant metastasis from 
colorectal cancer (CRC) or other gastrointestinal tract cancers (colorectal liver metastases 
[CLM]). CRC is a major cause of death due to cancer worldwide and the second leading cause 
of cancer mortality in Europe (1). Approximately 25% of patients with CRC present with liver 
metastases at diagnosis and up to 50% develop liver metastases over the course of the disease 
(6). Liver metastases are found in 6-25% of patients with metastatic breast cancer (8) and in up 
to 50% of patients with pancreatic cancer (9).  
The first-line treatment for hepatic tumors is surgical resection or transplantation. Liver 
transplantation is the optimal choice for patients with a single HCC or early multifocal disease 
and decompensated cirrhosis. However, only a small patient population will receive this 
treatment (about 5%) since eligibility for liver transplantation requires a unique tumor lesion <5 
cm in diameter or up to 3 tumor lesions <3 cm (3) confined to regions without major hepatic 
vessels.  
Surgical resection is the optimal first-line treatment for primary and metastatic liver cancer. 
However, few patients are suitable for surgery due to poor baseline function, overall tumor 
burden, or hepatic vessel invasion. Liver resection is also considered the only potentially 
curative treatment in patients with CLM providing significant improvement of overall survival 
(10). However, surgical resection with curative intent is only feasible for a minority of patients 
with liver metastases (10-25%) since only a small proportion of patients have resectable 
disease at disease presentation (11). Despite the survival advantage of hepatic resection on 
CLM, relapse is common following curative resection (12). In addition, surgery is an invasive 
procedure associated with high rates of morbidity and mortality (13).   
The use of systemic chemotherapy has also been attempted in patients with liver cancer. 
Unfortunately, HCC is a relatively chemotherapy-resistant tumor, therefore, outcomes using this 
treatment are unsatisfactory (14, 15). Also, systemic therapy is often ineffective with underlying 
cirrhosis, and it is only used in patient’s ineligible for surgical resection, liver transplant and local 
ablation. In addition, the use of chemotherapy is outweighed by frequent toxicity and lack of 
significant survival benefit. Radiotherapy is also an ineffective strategy for primary liver cancer. 
Radiation therapy is limited by dose-related radiation hepatitis, which precludes the 
administration of external beam radiation in doses effective for tumor eradication (16).  
Transarterial chemoembolization (TACE), based on the delivery of chemotherapeutic agents 
directly to the tumor lesions via the hepatic artery, has become one of the most widely accepted 
palliative therapy for unresectable HCC (17). However, complete necrosis rate of tumors after 
TACE only reaches 10-20%, and the prognosis of these patients remains poor (18-20).  

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Ablation techniques have emerged as promising alternatives for those patients who are not 
eligible for surgical resection or who have failed medical and/or radiotherapy therapies. Current 
ablation methods include non-thermal ablation methods such as percutaneous ethanol injection 
(PEI) and irreversible electroporation (IRE) and thermal modalities such as radiofrequency 
ablation (RFA), microwave ablation (MWA), and high-intensity focused ultrasound (HIFU) (3).  
The limitations of the non-thermal ablation methods:  For PEI, high rates of tumor recurrence 
and multiple treatment sessions required have limited the use of PEI in routine clinical practice. 
For IRE, most devices require simulation planning with the use of multiple probes placed in 
parallel to achieve the desired ablation zone. The requirement of multiple treatment sessions 
and the use of multiple parallel probes results in a significant increase in procedural cost and 
complexity. Also, IRE requires general anaesthesia with paralytic agents as the electrical 
current generated during the procedure can cause muscle spasms and arrhythmias (16). 
The limitations of thermal ablation methods: Despite the efficacy of some of these local thermal 
ablation modalities, significant limitations exist due to their mode of action (thermal tissue 
destruction). Thermal ablation is inconsistent in tissue with non-uniform heat dissipation 
patterns, which is common in hypervascular liver tumors (21). Thus, thermal ablation often 
results in incomplete tumor necrosis in tissue near major vessels (22, 23). Consequently, the 
shape and the size of the ablation zone may be unpredictable and the efficacy of thermal 
ablation may be restricted as multiple sessions are necessary to complete tumor ablation (24). 
In addition, thermal ablation methods are often unsuitable for treating tumors larger than 3 cm 
due to excessive treatment time and practical probe sizes (25-27). Besides, all ablation 
modalities available share a high rate of local recurrence in HCC. Most complications 
associated with use of RFA and MWA are consequences relating to thermal injury (28). Another 
limitation of these methods is the lack of imaging feed-back during treatment. Thus, the effect of 
ablation treatment is evaluated after the application of thermal treatment by CT or MRI while no 
real-time imaging provides monitoring during treatment (29).  
HIFU is a non-invasive, image-guided, thermal ablation method. Unlike percutaneous thermal 
modalities, HIFU is completely extracorporeal and lacks the risks of bleeding and tumor seeding 
with the direct puncture of tumors. HIFU may improve upon other thermal ablation modalities 
due to its non-invasiveness, real-time feed-back and the ability to scan the focal zone over a 
large volume (29). As the other thermal-based methods, HIFU is also limited by the heat-sink 
effect, resulting in reduced effectiveness in ablating tissue near major vessels and extended 
treatment time for larger hypervascular liver volumes (29). Also, a major challenge in the non-
invasive treatment of liver tumors using HIFU ultrasound is rib obstruction, which may result in 
secondary hot-spots near the treatment main focal zone, inducing loss of therapeutic precision 
and collateral damage (30). Moreover, because of the high ultrasound absorption coefficient of 
HIFU at the bone-tissue interface, overheating of ribs and surrounding tissue often results in 
unwanted tissue damage. Skin burns and subcostal edema have been reported with HIFU liver 
ablation cases (31, 32).  
Therefore, developing new strategies in which a liver tumor can be ablated non-invasively and 
avoiding thermal-related collateral damage and ineffectiveness would be a major clinical 
advancement in the treatment of soft tissues, particularly liver tumors. 
2.2 HISTOTRIPSY - NON-THERMAL; FOCUSED ULTRASOUND  
To address these unmet clinical needs, cavitation-based focused ultrasound (histotripsy) is a 
promising option to ablate liver tumors and overcome the limitations of currently available 
ablation modalities. 

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Histotripsy is an ablative technology that mechanically destroys targeted tissue through the 
precise targeting of acoustic cavitation (33-35). The VORTX RX® is an image-guided device 
designed to deliver non-invasive, non-thermal histotripsy for local ablation that has the potential 
to overcome many limitations of other ablation devices. 
The Histotripsy Group in the University of Michigan´s Department of Biomedical Engineering 
invented and pioneered the development of focused ultrasound histotripsy for more than twelve 
years. Starting with their earliest work of in the use of microbubbles to cause tissue damage, 
this group developed histotripsy into a highly controlled and predictable tool to remove 
unwanted tissue with microscopic precision. In 2010, HistoSonics, Inc. entered into a worldwide 
exclusive license with the University of Michigan for exclusive rights to the entire portfolio of 
histotripsy patents and patent applications. HistoSonics has advanced histotripsy toward clinical 
application with the development of the VORTX RX® medical device to deliver histotripsy. 
Histotripsy is based on the delivery of acoustic energy in the form of short (<50 microseconds) 
very high intensity pulses which induces controlled cavitation to mechanically homogenize 
targeted tissue (33). Cavitation is a process that occurs when a sufficiently negative pressure is 
applied to a fluid or tissue to cause microbubble formation from fluid vaporization and release of 
dissolved gas (36). Microsecond, high-pressure pulses applied by an ultrasound transducer 
outside the body and focused on the target tissue are used to generate a cluster of 
microbubbles. Once formed, the microbubbles exhibit highly dynamic patterns of oscillation and 
inertial collapse which impart severe stresses on surrounding cells and tissues to produce 
cellular and tissue destruction at the target (37). With sufficiently high pressure and adequate 
number of pulses, the target tissue can be completely destroyed, as demonstrated pre-clinically, 
creating a fluid homogenate with no recognizable cellular structures.  
Favorable characteristics of histotripsy ablation method:  
 
No insertion of probes or needle electrodes required 
 
Ultrasound imaging feed-back for pre-operative planning and real-time visualization of 
target tumor and image-guided tissue destruction 
 
Prevents damage to adjacent structures 
 
Overcomes rib obstruction 
 
Precise targeting 
 
Complete resorption of ablation zone 
 
Minimal scarring 
 
Immediate treatment imaging feed-back 
 
2.3 HISTOTRIPSY FOR LIVER TUMORS 
The characteristics of histotripsy provides for potentially significant benefit in the application for 
the ablation of liver tumors. Several preclinical studies were conducted that demonstrated the 
performance and safety profile of histotripsy to safely ablate liver tissue. Refer to the 
Investigator’s Brochure (IB) for a detailed description of those studies.   
As an overview, the following summarizes those key pre-clinical studies, conducted to provide 
foundational evidence of the feasibility of histotripsy to safely and effectively target and ablate 
the liver.  Various preclinical and bench models were employed in the following studies:  
Study 1 demonstrates in a porcine model that histotripsy can ablate liver tissue while preserving 
surrounding critical structures (29). Eight pigs were treated in this study.  Twelve lesions of ~1 

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cm3 were created in the livers of six pigs and two larger volume lesions of 18 cm3 and 60 cm3 
were generated in the livers of 2 pigs.  Histological evaluation of the lesions showed complete 
ablation of hepatic parenchyma inside the treated volume with sharp boundaries and only a 
small area of partially ablated liver tissue <500 μm likely caused by respiratory motion. There 
were no signs of damage to overlying skin, muscle, or ribs found. Histological evaluation 
showed no damage observed in any of the large vessels inside the treated region; no visible 
damage or perforation to the gallbladder was observed in harvested samples. 
Study 2 demonstrates in a porcine model that histotripsy transmitted through the ribs can safely 
and effectively ablate the liver without the need for aberration correction (38).  Non-invasive liver 
histotripsy ablations were generated in 8 pigs, with 4 lesions through acoustic windows with full 
ribcage obstruction and 4 lesions without rib coverage. The treatments were applied by a 750-
kHz focused transducer using 5 cycle pulses at 200 Hz PRF. Temperatures on overlying tissues 
including ribs were measured with needle thermocouples. Statistically comparable ablation 
volumes were generated for transcostal and transabdominal treatments. The average 
temperature increase on the ribs in all transcostal treatments was 3.9±2.1 ºC, while in 
transabdominal treatments an increase of 1.7±1.3 ºC was observed. No damage was observed 
on ribs and other overlying tissues.  
Study 3 demonstrates the chronic response and healing effect post-histotripsy in a rat model, 
with complete healing within 28 days (39). Histotripsy was applied to the livers of 20 rats 
through the intact abdomen transcutaneously at a pulse repetition frequency of 100 Hz. Lesions 
were generated by mechanically scanning the ablation focus in a 4 mm x 4 mm square grid 
inside the rat liver. Lesion progression of the rats was monitored with MRI on days 0, 3, 7, 14 
and 28 (n=4 each). Histologic evaluation of ablated liver lesions 1 hour after the procedure 
showed complete ablation, with no recognizable cellular structures within the ablated region. No 
signs of damage to overlying skin, muscle or ribs. The chronic response was assessed over 28 
days with the tissue homogenate inside the lesions being gradually replaced by regenerated 
liver parenchyma and scar. By day 28, the lesion was mainly replaced by normal parenchyma.  
Study 4 demonstrates histotripsy’s ability to ablate cancer cells in a mouse model (40). Liver 
cancer patient-derived xenografts (Hep3B HCC cell line) were subcutaneously implanted in 8 
NSG mice. When the tumors had grown to approximately ~1 cm in diameter, histotripsy ablation 
was applied non-invasively using a custom-built 1 MHz histotripsy therapy system designed for 
small animal experiments. Gross analysis and histological evaluation demonstrated that 
histotripsy ablated the targeted tumor into an acellular debris with no remaining cellular 
structures with sharp boundaries between treated and untreated tissue. Histology of the lung 
and brain was assessed in these animals 4 weeks after a partial tumor ablation, showing normal 
lung parenchyma and brain parenchyma with no HCC metastasis.  MRI showed nearly 
complete destruction of the tumor with only small nodules of residual tumor remaining after 
ablation, likely due to limitations in the murine model (i.e. unable to treat a margin around the 
tumor due to the subcutaneous location).   
Study 5 demonstrates, using imaging data and modeling, that there is ample acoustic window 
in the human for histotripsy access in greater than 90% of liver targets analyzed (internal 
Scientific Report (SR) No. 0203).  21 de-identified human CT data sets were collected with data 
from BMI categories ranging from <18.5 to >40 and were analyzed to assess the available 
acoustic window for target locations throughout the liver.  These data sets were segmented 
using Mimic so that various tissue types could be considered and analyzed in the acoustic 
aperture calculation. The collection of all possible acoustic apertures and focal pressures for 
these subjects was used to define a theoretical histotripsy transducer. The analysis determined 
that 93% of target liver points were accessible with the theoretical transducer when considering 
the assumptions of patient preparation (for gas removal) and pressure thresholds.     

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Study 6 confirms a strong safety profile in a porcine model wherein a supratherapeutic 
histotripsy dose was applied directly to major hepatic veins (SR 0204).  Histotripsy was applied 
non-invasively to 22 pigs (11 heparinized and 11 non-heparinized) using 5 cycle pulses applied 
at a pulse repetition frequency (PRF) of 50 Hz. Four histotripsy treatments were applied: 1 and 
15-minute treatments applied to a region of the liver adjacent to a large hepatic vein, followed by 
1 and 15-minute treatments applied within the hepatic vein (diameter ≥ 5 mm).  For all subjects 
(heparinized and non-heparinized), bubble clouds were successfully initiated in the liver and 
hepatic vein without inducing any significant changes in blood pressure, ECG, or SpO2. Small 
but significant decreases in heart rate and core body temperature were observed in both groups 
during the experiment, with these decreases likely being a response to the general animal 
procedures rather than histotripsy, consistent with intra-procedural observations noted before 
and between histotripsy treatments. All animals survived the treatment. Acute hypotension 
during treatment was observed in one subject which returned to baseline levels by the 1-hour 
post-treatment time point.  
With these foundational studies providing a strong proof of concept, the VORTX Rx® device was 
further developed for use in the ablation of soft tissues, including liver tumors.  As part of the 
development process, histotripsy was applied to livers using the VORTX Rx® in 48 porcine 
subjects (39 acute; 9 chronic) in a series of experiments, with the goal of safe, effective, and 
time efficient histotripsy ablation of the liver.  
 
In the first series, ablations were created in 30 minutes or less of energy delivery with 
results from contrast-enhanced MRI imaging and histology consistently showing 
complete ablations within the targeted tissue volume. Chronic animals were each 
survived 28 days (+/- 2 days) with the involution of the ablation zone resulting in an 
average reduction of 65% by the 28-day time point.  The ablations in these 24 subjects 
met the efficacy and time efficiency requirements, however, body wall effects were 
apparent in 13 of the 24 subjects (54%).   
 
The next 12 subjects were treated with thermocouples placed to study temperature rise 
as a function of various operating parameters and the research team conducted a 
rigorous study with theoretical analysis and bench testing to optimize device parameters 
to derive parameters that would deliver safe, effective, and time efficient ablations.  
 
The next series of experiments was an in-vivo acute porcine model with 6-animal livers 
ablated with the same procedural protocol as the previous subjects using the 
parameters derived from the thermocouple studies.  The ablations in all 6 subjects were 
excellent as confirmed with both imaging and histology.  None of the 6 subjects showed 
any signs of body wall effects.  
 
The next step was a Good Laboratory Practice (GLP) confirmatory study to demonstrate 
that the system developed could safely and effectively ablate a clinically relevant 
volume of liver tissue using the system and workflow in the same manner as it would be 
used clinically. Clinically relevant ablation volumes were generated in six additional 
porcine subjects using these optimized parameters in a study which confirmed the 
device, the VORTX Rx®, is safe and effective. Please see IB for additional details. 
 
2.4 CLINICAL EXPERIENCE WITH THE VORTX RX® 
2.4.1 BENIGN PROSTATIC HYPERPLASIA  
The VORTX Rx® is a platform technology. This means some aspects of the platform hardware 
and software can be leveraged for different indications using different device configurations. As 

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an example, in 2013, a previous configuration of the VORTX Rx® was approved by the United 
States Food and Drug Administration (US FDA) under an Investigational Device Exemption 
(IDE) for use in a human pilot trial indicated for benign prostatic hyperplasia (BPH) treatment. 
The VORTX Rx® BPH-indicated configuration had hardware and software similar to the current 
investigational device adapted for soft tissue ablation. This design was a portable ultrasound 
device to apply histotripsy ablation used in this human trial for non-invasive image-guided 
ablation in male subjects with benign prostate enlargement.  
Under the FDA-approved IDE, a prospective, non-randomized pilot study was conducted in two 
centers in the United States. The primary objective of this first-in-human (FIH) study was to 
evaluate safety of the device for treatment of BPH and secondarily to perform an initial efficacy 
assessment using histotripsy ablation. Twenty-five adult men in a first cohort and three 
additional men in a second cohort with moderate to severe symptomatic BPH received an 
ablation. Using the VORTX Rx®, 60 minutes of non-invasive acoustic energy (histotripsy) was 
delivered through the perineum to the prostate with real-time transrectal ultrasound monitoring.  
Subjects were either under general anesthesia or IV-sedation (based on investigator and patient 
preference). All patients who received an ablation were followed up at post-operative day 1, and 
1, 3 and 6 months after treatment.  
An excellent safety profile was established. No study-stopping adverse events (AEs) occurred 
(no deaths, major bleeding or fistulas). Device-related AEs (definitely or probably device-related 
per the DSMB) were limited to 3 cases of transient retention (<3 days), 1 case of intermittent 
retention (8 days), a minor anal abrasion and 1 case of microhematuria.  
This study concluded that ablations delivered using the VORTX Rx® were well-tolerated, safe 
and led to significant improvements in patient-reported symptoms using the International 
Prostate Symptom Score validated tool (IPSS), without measurable changes in objective 
measures such as uroflow. See the IB for additional discussion on this clinical experience of the 
VORTX Rx®. 
2.4.2 VORTX RX® FOR LIVER TUMORS 
HistoSonics is currently focused on developing the VORTX Rx® for the ablation of soft tissues. 
Within the application of soft tissues, the company is currently interested in studying ablation of 
liver tumors, given the significance of this unmet clinical need. The HistoSonics VORTX Rx® 
platform device has now been designed and configured for non-invasive, non-thermal, real-time 
image-guided procedures including soft tissue ablation, particularly liver tumors.  
2.5 STUDY RATIONALE 
As noted above, surgical resection is the optimal first-line treatment for primary and metastatic 
liver cancer. However, few patients are suitable for surgery due to poor baseline function, 
overall tumor burden, or hepatic vessel invasion. In addition, surgery is an invasive method 
associated with a high morbidity. Chemotherapy and radiotherapy treatments are often 
ineffective treatment strategies for liver cancer treatment, outweighed by frequent toxicity or 
collateral damage (41).  
Ablation techniques have emerged as promising alternatives for those patients who are not 
eligible for surgical resection or who have failed medical and/or radiotherapy therapies. 
However, despite the efficacy of some of these local thermal ablation modalities, significant 
limitations exist due to their mode of action (thermal tissue destruction), including the heat sink 
effects from blood flow through the highly vascular liver, often resulting in incomplete tumor 
ablation or inability to treat near major blood vessels (25-27). In addition, uncontrolled thermal 
spread (ablating beyond planned volumes) increases the potential for damage to adjacent 
structures. Therefore, developing new strategies in which a liver tumor can be ablated non-

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invasively and avoiding thermal-related collateral damage and ineffectiveness would be a major 
clinical advancement in the treatment of soft tissues, particularly liver tumors. 
To address these unmet clinical needs, cavitation-based focused ultrasound (histotripsy) is a 
promising option to ablate liver tumors and overcome the limitations of currently available 
ablation modalities. Histotripsy is a non-invasive, non-thermal, image-guided focused ultrasound 
ablative technology that uses mechanical properties of focused ultrasound to ablate targeted 
tissues through the precise delivery of acoustic cavitation. Histotripsy has the potential to target 
multiple sites without the need for incisions or needle insertions (which may cause bleeding, 
infection, and/or tumor spread). Because histotripsy is non-thermal, it is not affected by the heat 
sink effect from blood vessels and does not have the limitations associated with thermal ablation 
such as collateral damage due to uncontrolled thermal spread. In addition, histotripsy may be 
able to overcome the interference challenge from overlying ribs better than other ablation 
methods. It has been demonstrated preclinically that histotripsy can generate liver ablations 
using acoustic energy transmitted through the ribcage without inducing unwanted thermal 
effects or damage to overlying tissues. Liver ablation using histotripsy results in complete 
ablation of target tissue into an acellular homogenate that is absorbed by the body and replaced 
by normal liver parenchyma over time.   
As has been demonstrated through extensive preclinical experience described in Section 2.3 
above and further described in the IB, histotripsy is a potential paradigm-shifting technology. 
The non-thermal and non-invasive characteristics of histotripsy offer patients the potential for a 
soft tissue/tumor ablation with fewer clinical complications and adverse events than currently 
available ablation methods and surgical procedures. 
The safety of the VORTX Rx® has been demonstrated through rigorous performance testing to 
include bench and preclinical acute and chronic studies. This clinical study is intended to 
evaluate technical performance, including acute technical success, while collecting safety-
related data of ablation using the VORTX Rx®.  
2.6 RISK-BENEFIT ASSESSMENT 
There are no guaranteed benefits to subjects from participation in this study. However, patients 
with primary and metastatic liver disease included in this study may benefit from the ablation of 
up to three tumors by where a complete or partial removal of targeted tumor tissue will be 
performed using the study medical device. Therefore, there is a potential for tumor debulking for 
reduced overall tumor burden, leading to a favorable impact in the prognosis and quality of life 
for these patients who are not candidates for surgical resection and not suitable candidates for 
other locoregional treatments or have not responded to conventional therapies. The 
characteristics of cavitation-based focused ultrasound may allow a successful ablation of liver 
tumor with fewer complications than currently available liver ablation modalities and surgical 
procedures.  
The potential risks associated with the VORTX Rx® when used for the ablation of liver tumors 
are expected to include potential risks typically associated with ablation methods, ultrasound-
imaging related risks, patient positioning-related complications and risks related to the skin 
contact with the transducer coupling device. In addition, considering that patients will undergo 
the procedure under general anesthesia, there is the potential for anesthesia-related 
complications.  
 

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Potential risks typically associated with ablation methods 
Side effects according to state-of-the-art tumor ablations reports are expected, undesired 
complications of the procedure that although occurring commonly, rarely, if ever, result in 
substantial morbidity and mortality (42-46). The more serious complications described include, 
but not limited to, hemorrhage requiring transfusion, visceral perforation (bowel or stomach), 
biliary leakage or strictures, liver failure, myocardial infarction, lung damage, or embolism. Other 
complications may be abscess, soft tissue or skin lesions and burns, damage to vascular 
system, thrombosis, ascites, subcapsular hematoma, cryo-shock, post-ablation syndrome (low-
grade fever, malaise, chills, myalgia delayed pain, and nausea and vomiting), pleural effusion, 
asymptomatic pleural effusions and minimal asymptomatic perihepatic (or renal) flood or blood 
collections seen at imaging (42-47).   
As noted above, thrombosis is a possible adverse event resulting from tumor ablation.  In the 
preclinical studies conducted in support of the VORTX Rx® product development, localized 
thrombosis was observed in 58% of preclinical subjects receiving histotripsy ablations in the 
confirmatory study phase.     
As a possible adverse event in this clinical study, all subjects will be closely monitored for 
thrombosis or embolism and, if so determined to be of clinical importance, will be treated with 
standard local clinical practice appropriate for the individual patient.   
 
Ultrasound energy delivery-related clinical risks 
The study device delivers ultrasound energy to ablate liver tumors targeted by the clinician. 
Real-time ultrasound imaging will be used in combination with focused ultrasound ablation in 
order to provide ablation planning, image-guided targeting, and intraprocedural imaging 
feedback to the physician during the procedure. This introduces clinical risk to the patient that is 
typical for other ablation methods that are monitored with ultrasound imaging during the 
ablation. Moreover, the intervening tissues in the energy pathway are potentially at risk of 
physical effects associated with ablative ultrasound. 
 
Patient´s position  
The patient will remain under general anesthesia in a supine position on a procedure table 
throughout the procedure with the chest/abdomen coupled to the device transducer supported 
by a fixed (non-active) articulating arm that locks in place. This introduces clinical risk to the 
subject that is typical of being placed in this position.  
 
Skin contacting during the procedure 
The skin will be in contact with the device transducer via an Ultrasound Medium Container 
(UMC) to include a 3M Ioban™ drape, coupling container and approximately 1.5 liters of 
degassed water, which introduces a clinical risk regarding potential skin sensitivity or reaction to 
patients with known sensitivity to iodine (contraindication) see the User Manual for further 
information. It should be noted that through the device development process, biocompatibility 
risks have been minimized by limiting patient contact exposure, use of known state-of-the-art 
contacting materials and the clinical centers’ water resources.   
 

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General anesthesia 
Patients will be under general anesthesia during the procedures, as respiration needs to be 
controlled. The potential occurrence of anesthesia-related complications must therefore be 
considered. However, only patients who can undergo general anesthesia will undergo ablation 
procedure. Anesthetic risk will be assessed at screening and before each ablation procedure 
performed during the study (multiple tumors and/or retreatment of tumors).  
 
Risk-Benefit Summary/Conclusion:  
Several measures will be taken to ensure that the potential benefits outweigh the potential risks 
for patients participating in this study. Measures include:   
 
careful selection of patients; 
 
a detailed pre-procedure assessment;  
 
complete training and qualification of investigators;  
 
close monitoring of the study device and rigorous post-ablation follow-up.  
There is reasonable assurance that the VORTX Rx® device is safe to take into the clinical 
setting based on: 
 valid scientific evidence from bench and preclinical data,  
 the application of risk management processes to the development of the medical device 
(per EN ISO 14971),  
 the sponsor’s plan for compliance with design, conduct, recording and reporting of this 
clinical investigation per Clinical investigation of medical devices for human subjects - 
Good Clinical Practice (EN ISO 14155),  
 compliance with other applicable regulatory requirements,  
 together with a study design similar to clinical evaluations of similar ablation technology 
(see the Manufacturing Standards section of the IB for Manufacturing Standards). 
In addition, the probable benefits to health for this palliative patient population from use of the 
study device, for its intended uses, and conditions of use, when accompanied by adequate 
directions and warnings against unsafe use, outweigh the probable risks. 
3 
STUDY OBJECTIVES 
3.1 PRIMARY OBJECTIVE 
The primary objective of the study is to evaluate the acute technical performance of the VORTX 
Rx® medical device for the ablation of primary and metastatic liver tumors. 
3.2 SECONDARY OBJECTIVES 
 
Assessment of the safety profile of the VORTX Rx®.  
 
Assessment of local tumor progression by MRI at 1 week, 1 month and 2 months, post-
procedure.  
 
Assessment of the involution of the ablation zone 1 week, 1 month and 2 months post-
procedure.  
 
Assessment of liver panel.  

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 
Immunologic assessment. 
 
Evaluation of quality of life. 
 
Assessment of pain and analgesic requirements after the ablation procedure.  
4 
STUDY ENDPOINTS 
4.1 PRIMARY ENDPOINT 
 The primary endpoint of the study is acute technical success, consisting of success in treating 
the PAV, defined as the ability of the investigational device to create an ablation zone per the 
PAV (a three-dimensional volume defined by the investigator using the VORTX Rx® in the 
planning phase of the software workflow), as measured by multi-dimensional imaging and 
characterized qualitatively in the radiological report 1-day post ablation. The acute technical 
success of up to 3 separate tumor ablations in a single patient will be assessed 
4.2 SECONDARY ENDPOINTS 
 
The safety profile of the VORTX Rx® will be measured based on all adverse events (AEs) 
(serious and non-serious) that are probably or definitely device-related and experienced 
during the use of the medical device as well as those AEs and abnormal findings on 
physical examination, vital signs, laboratory, ECG and imaging tests through the study.  
Adverse Events will be captured in compliance with ISO 14155 (48), MEDDEV 2.7/3 rev 3 
(49) and classified and graded according to the National Cancer Institute Common 
Terminology Criteria for Adverse Events (NCI-CTCAE) version 4.0 (Appendix 2). 
The incidence of any of the following serious adverse events (SAEs), if definitely attributable 
to the device under study, will be evaluated: 
1. Major bleeding that requires transfusion within 48 hours 
2. Visceral perforation (bowel or stomach)  
3. Major biliary duct injury 
4. Death 
The study will be considered to have a favorable safety profile given the following 
outcomes:  
 
No deaths due to the ablation,and 
 
No deaths from visceral perforation (bowel or stomach), and 
 
20% or lower incidence of major bleeding requiring transfusion within 48 
hours, and  
 
20% or lower incidence major bile duct injury. 
 
The ablation zone created as a result of the ablation of each tumor (multiple tumor 
ablation sessions and/or retreatment) will be assessed post-procedurally to evaluate 
local tumor progression by contrast-enhanced MRI imaging at 1 week, 1 month and 2 
months. Evaluations may be supplemented with optional CT or ultrasound with or 
without contrast imaging at the discretion of the investigator.  
 
The involution of the ablation zone of each tumor lesion (multiple tumor ablation 
sessions and/or retreatment) will be assessed post-procedurally by contrast-enhanced 
MRI imaging at 1 week, 1 month and 2 months. Evaluations may be supplemented with 
optional CT or ultrasound with or without contrast imaging at the discretion of the 

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investigator. Ablation zone dimensions will be determined at each time point for each 
tumor.  
 
Liver panel will be evaluated on the basis of the change of aspartate transaminase 
(AST), alanine transaminase (ALT), alkaline phosphatase, albumin and bilirubin, 
gamma glutamyl transpeptidase (GGT), prothrombin time (PT) and international 
normalized ratio (INR) from baseline to evaluation visits 1 day, 1 week and 1 and 2 
months post procedure for each tumor ablated.  
 
Immunological response of ablation will be evaluated on the basis of immune tests 
conducted and tumor biomarker assessments (including, but not limited to, immune 
tests: CD3+, CD4+, CD8+, CD45+, CD16+, CD56+ and CD19+, C-reactive protein 
[CRP], complement C3, C4 and CH50, immunoglobulins [IgG, IgM, IgA], interleukin-6 
[IL-6], carcinoembryonic antigen [CEA], alfa-fetoprotein [AFP], Cancer Antigens CA15-3  
[Breast Cancer] (50) and CA 19-9 [Pancreatic Cancer] (51)) from baseline to evaluation 
visits 1 day, 1 week and 1 and 2 months post procedure for each tumor ablated. 
 
Measure Quality of life (QoL) on the basis of the score of the European Organization for 
Research and Treatment of Cancer (EORTC) QLQ-C30 (58) (Appendix 4) at baseline 
and at 1 and 2 months post procedure for each tumor ablated.  
 
Perform pain assessment by a 100 mm visual analog scale (VAS) where 0 is “no pain” 
and 100 is “the maximum pain possible” (Appendix 5) at 1-day and 1-week post-
procedure for each tumor ablated. 
 
Evaluate analgesic treatment prescription in the 24-hour period post-procedure and 
during the one week period post-procedure for each tumor ablated.  
 
5 
STUDY DESIGN 
5.1 OVERALL STUDY DESIGN 
This is an open-label (no-masking), non-randomized, multi-center study comprised of three (3) 
independent centers located in the greater metropolitan Barcelona area.  
The PI and study coordinator, Dr. Joan Vidal-Jove, will performance all ablation procedures 
during the study.  
The primary objective of this study is to evaluate acute technical performance of the VORTX 
Rx® medical device for the ablation of primary and metastatic liver tumors.  
Ablation of the targeted tissue will be evaluated using MRI analysis following a predefined 
imaging protocol to assess acute technical success defined as the ability of the investigational 
device to create an ablation zone per the planned ablation volume (PAV) (a three-dimensional 
volume defined by the investigator using the VORTX Rx® in the planning phase of the software 
workflow). CT analysis may also be utilized per investigator discretion. 
The pre-specified technical success criteria and imaging protocol greatly reduces the possibility 
of unplanned changes being made based on interim trial findings, reducing operational bias and 
supporting findings of scientific integrity of this study.  
Up to three separate ablation sessions will be allowed to be performed in a single patient during 
the study with a minimum of 1 month between sessions. It will be allowed to treat more than one 

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tumor in the same session whenever the total volume of the tumors ablated is determined to be 
less than or equal to the volume of a single 3 cm diameter tumor. Each tumor is required to 
meet the criteria defined for a targeted tumor in the study protocol: diameter of less than or 
equal to 3 cm (≤3 cm) and clearly separated from other tumors or other critical areas (i.e. 
located in different segments of the liver).  
Targeted tumors can be retreated upon investigator discretion (i.e. in case that residual tumor is 
detected). Retreatment of a tumor will be performed 1 month after the prior ablation of the 
tumor. 
In all cases, at least a one-month period must have elapsed between the last ablation 
performed and the next ablation session.  
Retreatment of a tumor and ablation of a new tumor are not allowed to be performed in the 
same session. Any required re-treatment will be performed prior to any new treatment in any 
individual patient. Treatment of a new tumor in a new patient will be allowed prior to retreatment 
of a tumor in a previous patient. 
Medical history review, ECOG PS, physical examination, including vital signs, and anesthetic 
risk assessment will be carried out before ablation of additional tumors (up to 3 ablation 
sessions) or tumor retreatment is performed. Only patients who can undergo general anesthesia 
will undergo ablation procedure. Anesthetic risk will be assessed at screening and before each 
ablation procedure performed during the study (multiple tumors and/or retreatment of tumors) 
using the American Society of Anesthesiologist (ASA) score. The ASA score will be used to 
assess the physical status of patients before the procedure and estimate pre-operative risk. 
The study enrollment period is expected to require up to twelve (12) months and the study 
follow-up period per patient will be a minimum of two (2) months with a maximum follow up 
period to be determined by the number of tumors ablated and what is medically appropriate. 
However, it is anticipated that no more than nine (9) months should be required to complete 
patient follow up, or until the withdrawal of the patient due to any reason, whichever is first. 
Therefore, the total study duration may extend to approximately 21 months.  
The study will consist of a screening period (within the 2-month period prior to the ablation 
procedure), pre-planning visit including a procedure simulation (within a week prior to the 
procedure visit) and a procedure visit where the ablation will be performed using the study 
device, and 4 post-ablation study visits 1 day, 1 week and 1 and 2 months post-ablation. This 
schedule will apply for each tumor ablated (or combinations of tumors ablated in the same 
session) (up to a total of 3 separate ablation sessions) and for retreated tumors.  
Once informed consent has been obtained, and the fulfillment of all pre-selection criteria has 
been confirmed, the patient will be scheduled for the ablation procedure. All selection criteria 
must be confirmed the day of the ablation procedure to consider the patient eligible to undergo 
the procedure. A patient will be considered enrolled once the first pulse of the ablation energy 
has been applied to the tumor. Patients will be hospitalized to undergo the procedure, which will 
be performed at the study site. Patients will undergo a detailed post-procedure evaluation within 
24 hours of the ablation and they will be discharged from the hospital whenever they do not 
present any complication that requires extended hospitalization. Follow-up evaluation will 
include imaging assessment, measurement of laboratory parameter levels, including liver 
enzyme panel, immunological parameters and tumor biomarkers, ablation zone evaluation and 
record of adverse events.  
For safety purposes, this study will take a two (2) step approach:  
Step 1: 
a. The first subject enrolled will be observed and assessed over a 24-hour period and shall 
not have experienced any unexpected SAE attributable to the study device.  

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b. After completion of Step 1a, the second subject enrolled will be observed and assessed 
over a 24-hour period and shall not have experienced any unexpected SAE attributable 
to the study device.    
Step 2:  
 
Once Step 1a and 1b are complete, the remaining subjects, after meeting all inclusion 
(and no exclusion) criteria may be enrolled and treated on a first-come, first-served 
basis.  
Should the first or second subject experience an unexpected serious adverse event attributable 
to the investigational device, the principal investigator will consult with the Data and Safety 
Monitoring Board (DSMB), his co-investigator(s) and the sponsor and together determine the 
appropriate next course of action regarding study. If after such consultation and review, it is 
determined that the study resume, a third patient will be enrolled and monitored in a similar 
fashion before commencing with successive enrollment.    
An independent DSMB will be used for review of safety data to provide advice to the Sponsor to 
ensure the safety, protection and well-being of the subjects enrolled in the study. The members 
of the DSMB will be experts who are independent from the Sponsor. Additional details regarding 
the structure of the DSMB is provided in Section 9.5. 
The video recording of the ablation procedure is intended to be performed for all patients 
participating in the study for research purposes and for feedback for engineering improvements. 
The video recording will be performed by the investigator and his collaborators during the 
ablation procedure at the surgery room of the centre. Only the areas restricted to the liver area 
will be recorded, avoiding, as far as possible, areas of their body by which they can be identified 
(for example tattoos, scars or recognizable birthmarks). The recording will be identified using 
numeric codes (no data that identify you will appear), maintaining confidentiality at all times in 
accordance with current legislation and regulations. The video recording of the procedure is 
totally voluntary. The patient will be informed about the conditions of the video recording and it 
will not be performed until the patient has given his/her informed consent for the obtaining and 
publishing of the video recording for research purposes. The patient could give his/her consent 
to participate in the study without authorizing the recording of the procedure. The current 
legislation on the protection of personal data (Data Protection Regulation (EU) 2016/679) will be 
applied.  
During the study it is also intended to collect an extra amount of blood at each study visit when 
blood samples are taken for hematology and biochemistry evaluation and for immunological and 
tumor markers assessment as part of the study procedures. These additional blood samples will 
be sent (along with the blood samples drawn for study laboratory assessments), processed and 
stored at the central laboratory (Echevarne Laboratory, Barcelona) to be available for additional, 
originally unforeseen studies and or new scientific evidence arises in this field of research. 
Additional blood samples collected for research purposes will be sent to the central laboratory 
according to the instructions included in the Central Laboratory Sampling Manual provided to 
the investigators. The procedure of blood sample collection, identification of samples (labeling), 
storage conditions, and shipment details will be included in the Central Laboratory Sampling 
Manual. Once the clinical trial is completed, all additional blood samples obtained during the 
study will be stored in the central laboratory where these samples will be preserved for up to 3 
years for future investigation. The storage of biological samples will meet the ethical and legal 
requirements provided in the RD 1716/2011. The biological samples will be handled, stored, 
and treated according to the Law 14/2007 of biomedical research, which regulates the use of 
biological samples for such purposes. The collection of these additional blood samples is 
completely voluntary. The patient will be informed about the conditions of the collection, storage 
and use of the additional blood samples and they will not be drawn until the patient has given 

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his/her informed consent for this purpose. The patient could give his/her consent to participate 
in the study without authorizing the collection of additional blood samples.  
Further details on study periods and procedures are provided in section 5.4. 
 
Figure 1. Study design 
 
 
 
5.2    TREATMENT ASSIGNMENT OR RANDOMIZATION 
There will be no treatment blinding, as this is an open-label study. This is a non-randomized 
study (no masking).  
5.3 STUDY POPULATION 
This study will include up to ten (10) subjects meeting all the inclusion criteria described in 
sections 5.3.1 and none of the exclusion criteria specified in section 5.3.2, and giving their 
informed consent to participate in the study. 
5.3.1 INCLUSION CRITERIA 
Subjects are eligible for the study if all of the following criteria are met: 
 
Written informed consent before any study procedure is performed. 
 
Subjects of both sexes aged 18 years or older. 
 
Patients diagnosed with liver cancer, including HCC or liver metastases from breast, lung, 
pancreas and/or colorectal cancers. If biopsy is required, there will be a minimum of 2-week 
period after biopsy and before the ablation.  
o 
HCC patients must meet the United Network for Organ Sharing and Organ 
Procurement and Transplantation Network (UNOS-OPTN) class 5 criteria for HCC 
(52).  
Screening*
(within 2 months
priorto Ablation)
Screening
Histotripsy
Ablation
Visit 1
Day 1
after
ablation
Visit 2
1 week after
ablation
Visit 3
1 month after
ablation
Visit 4
2 months
after
ablation
Visit 5
Follow-up visits
Histotripsy
Ablation
Visit1
Day1
after
ablation
Visit2
1 weekafter
ablation
Visit3
1 monthafter
ablation
Visit4
2 months
after
ablation
Visit5
Histotripsy
Ablation
Visit 1
Day1
after
ablation
Visit 2
1 weekafter
ablation
Visit 3
1 monthafter
ablation
Visit 4
2 months
after
ablation
Visit 5
Tumor 1
Tumor 2
Tumor 3
This visits may 
coincide
This visits may 
coincide

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o 
Liver metastases patients must meet minimum criteria of liver biopsy and/or tissue 
diagnosis of primary tumor or metastatic tumor with new or growing liver tumors 
radiologically consistent with metastases.  
 
Patients with liver cancer not candidates for surgical resection and/or not suitable for other 
locoregional treatments or patients who have not responded to or relapsed from 
conventional therapies.  
 
Previous treatment with chemotherapy and/or radiotherapy is permitted provided that these 
treatments have been discontinued more than 2 weeks before the ablation of the targeted 
tumor and whenever patients have recovered from any related toxicity (53).  
 
Previous treatment with immunotherapies is permitted provided that these therapies have 
been discontinued at least 4 weeks before the ablation and whenever patients have 
recovered from any related toxicity.  
 
Previous ablation/surgery on other tumors different from those that will be targeted with the 
VORTX Rx® is allowed whenever a minimum of 2 weeks has elapsed since the prior 
procedure(s).   
 
Tumor(s) to be targeted for ablation will be clearly separated from other tumors or other 
critical areas upon investigator´s criteria.  
 
Largest diameter of targeted tumor(s) ≤3 cm.  
 
Tumor(s) that will be targeted at a depth <10 cm from the skin surface.  
 
Must have an adequate acoustic window in the abdominal space to be able to visualize 
targeted tumor(s) using ultrasound imaging; also must be able to visualize targeted tumor 
using MRI with optional CT imaging at investigator discretion.  
 
Patients who can safely undergo general anesthesia. 
 
Liver function score of Child-Pugh A or Child-Pugh B. 
 
ECOG PS 0, 1 or 2 at screening.  
 
Adequate liver function (ALT and AST < 2.5 x upper limit of normal [ULN]), renal function 
(serum creatinine <2 ULN and/or bilirubin <2.5 UNL) and hematologic function (neutrophil 
count > 1.0 x 109/L and platelet > 50 x 109/L).  
 
An INR <2 within the last 7 days prior to the ablation in patients receiving anticoagulants, 
and an INR <1.5 for patients not treated with anticoagulants.    
 
Platelets level >50 x 109/L within the last 7 days prior to the ablation. 
 
5.3.2 EXCLUSION CRITERIA 
Patients are not eligible for participation in this study if one or more of the following criteria are 
met: 
 
Patients who decline or are unable to understand, provide or are unwilling to sign an 
informed consent form. 
 
Pregnant or nursing (lactating) women; women of childbearing potential and sexually active 
that are unwilling to use adequate contraception (such as oral contraceptives, intrauterine 
contraceptive device or barrier method with spermicide or surgical sterilization).  
 
Targeted tumor(s) not clearly separated.  
 
Targeted tumor(s) >3 cm. 
 
Tumor that will be targeted >10 cm from the skin surface.  
 
Tumor not clearly visible with diagnostic ultrasound and MRI. 
 
Liver function score of Child-Pugh C. 

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 
Liver volume reserve <40% as measured by CT Scan (54). 
 
Major surgical procedure, biopsy or significant traumatic injury <2 weeks prior to the 
procedure or has not recovered from side effects/complications of such procedure or 
trauma. 
 
Patient who has not recovered to grade 1 or better from any AEs (except alopecia, fatigue, 
nausea, vomiting) related to previous anti neoplastic therapies. 
 
BMI >30. 
 
Parkinson’s disease. 
 
History of bleeding disorders (e.g. von Willebrand disease) or patients suspected to have a 
bleeding disorder. 
 
Not able to temporarily discontinue warfarin, clopidogrel or any other long-acting 
anticoagulants at least two weeks before the procedure.  
 
Initiation of any anticancer treatment during the screening period.  
 
Life expectancy to be less than 6 months. 
 
ASA score ≥ 4. 
 
Unable or unwilling to complete all required screening and/or follow-up assessments.  
 
Patients under ongoing treatment with an investigational medication or medical device that 
conflicts with the study device. 
 
Patients for whom the investigator considers that the ablation is not in the patient's best 
interest.  
 
Patients with active alcohol or drug addiction or any other condition that, in the investigator’s 
opinion, would interfere with their ability to comply with the study requirements. 
 
Patients with any concurrent condition that, in the investigator’s opinion, would jeopardize 
the safety of the patient or compliance with the protocol. 
 
Patients with known sensitivity to topically applied iodine. 
5.3.3 WITHDRAWAL CRITERIA 
Patients may voluntarily discontinue from the study or be withdrawn at the discretion of the 
investigator at any time.  
Patients will be informed of their right to discontinue the study at any time and for any reason 
without incurring any prejudice for further medical attention.  
The investigator must withdraw the patient from the study if any of the following occur:  
 
The study is terminated. 
 
Consent for study participation is withdrawn. 
o 
Patients may voluntarily withdraw consent to participate in the study for any 
reason at any time. Withdrawal of consent occurs only when a patient does not 
want to participate in the study any longer, and does not want any further visits 
or assessments or study-related contact. 
o 
If a patient withdraws consent, the patients must be withdrawn from the study 
and no further assessments conducted. The investigator will record this 
decision in the patient’s chart and on the appropriate electronic CRF (eCRF) 
pages. Further attempts to contact the patient are not allowed unless safety 
findings require communication or follow-up. 
 
The patient becomes pregnant. 

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 
Further participation would be injurious to the patient’s health or well-being in the 
investigator’s medical judgment. 
 
Use of any prohibited medication (see Section 7.2).  
 
Use of ablation methods different from that described in the present investigational plan. 
 
Major protocol violations.  
 
The patient is lost to follow-up. 
o 
For patients whose status is unclear because they fail to appear for study visits, 
without stating an intention to withdraw consent, the investigator should show 
due diligence to contact the patient and document it in the source documents. A 
patient should not be considered lost to follow-up until due diligence has been 
completed. Patients lost to follow-up should be recorded as such on the 
appropriate disposition eCRF page. 
 
Administrative problems. 
Should a patient be withdrawn from the study, all efforts will be made to complete and report the 
observations as thoroughly as possible, including the reason for premature study end (i.e. lost to 
follow-up (LTFU), consent withdrawn, adverse events, etc.). For LTFU all reasonable effort to 
ascertain the reason(s) (i.e. telephone calls, mail) while fully respecting the subject's rights (ICH 
E-6 Good Clinical Practice). 
In patients who withdraw from the study before ending the established study period, the 
assessments and collection of data related to the last visit planned just before withdrawal should 
be performed. If such withdrawal is due to problems related to the investigational device safety 
or performance, the investigator shall ask for the subject's permission to follow his/her 
status/condition outside the clinical investigation. In cases of informed consent withdrawal, no 
data will be collected after informed consent withdrawal and patients will be followed up as per 
routine clinical practice.   
Patients who are withdrawn from the study are not eligible to re-enter the study. 
 
5.4 STUDY PERIODS AND DURATION 
The study will consist of a screening period during the 2-month period before the ablation 
procedure, which will include a preplanning simulation visit within a week prior to the planned 
ablation, the ablation procedure (one day), and 4 post-ablation study visits one day, one week 
and 1 and 2 months post-ablation per tumor as it is specified in Table 1. This study schedule will 
apply for the each tumor ablated (multiple tumors or retreatment of tumors).  
The study visits may coincide considering that a one-month period should be elapsed between 
ablation sessions (in case of multiple ablation sessions) and taking into account the monthly 
periodicity of the post-ablation follow-up. Therefore, in case of coincident post-ablation visits, if a 
laboratory test has been performed within the last week as a part of the post-ablation follow-up, 
it will not be necessary to repeat this assessment. Similarly, the imaging assessment will be 
performed once in case of coincident post-ablation visits.  
Table 1 lists all assessments and indicates with an “X” the visits when they are performed. All 
data obtained from these assessments must be supported in the patient’s source 
documentation and transcribed to the electronic case report form (eCRF).  

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Table 1. Visit evaluation schedule 
 
 
Screening 
Ablation 
for each 
targeted 
tumor(s) 
(baseline) 
Post-ablation follow-up visits per ablation session 
(in case of multiple targeted tumors or tumor 
retreatment) 
Visits 
 
1 
2 
3 
4 
5 
Days/weeks/months 
(Days -60 to -
1) 
 
1 day post 
ablation 
7 days  
post 
ablation 
1 month  
post 
ablation 
2 months  
post 
ablation 
 
 
 
 
± 2 days 
± 1 week29 
± 1 week30 
Informed consent1 
X 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
Demographic data 
X 
 
 
 
 
 
Medical history2 
X 
 
 
 
 
 
Data related to liver cancer3 
X 
 
 
 
 
 
Physical examination 
X 
 
X 
X 
X 
X 
Anthropometric data4 
X 
 
X 
X 
X 
X 
Vital signs5 
X 
X 
X 
X 
X 
X 
SO2 
 
X 
 
 
 
 
ECOG PS6 
X 
 
X 
X 
X 
X 
Child-Pugh score for 
hepatopathy assessment7 
X 
 
X 
X 
X 
X 
Liver volume reserve 
assessment by CT 
X 
 
 
 
 
 
12 lead ECG 
X8 
 
 
 
 
 
Complete blood count 
X9 
 
X 
X 
X 
X 
Basic metabolic panel 
X10 
 
X 
X 
X 
X 
Liver panel 
X11 
 
X 
X 
X 
X 
Urinalysis 
X12 
 
X 
X 
X 
X 
Immunologic parameters 
X13 
 
X 
X 
X 
X 
Tumor biomarkers 
X14 
 
X 
X 
X 
X 
Additional blood samples 
collection for future research 
purposes (optional)15 
X 
 
X 
X 
X 
X 
Serum pregnancy test16 
X 
 
 
 
 
 
Imaging assessment of liver 
tumor 17 
X 
 
 
 
 
 
American Society of 
Anesthesiologist score18 
X 
 
 
 
 
 
QLQ-C3019 
X 
 
 
 
X 
X 
Procedure-related data 
 
X20 
 
 
 
 
Video recording of ablation 
procedure (optional) 
 
X21 
 
 
 
 
Imaging assessment of ablation 
zone 
 
X22 
X23 
X23 
X23 
X23 
Ablation zone involution 
assessment24 
 
 
X 
X 
X 
X 
Medications administered post 
ablation25 
 
X 
X 
X 
X 
X 
Transfusions requirement26 
 
 
X 
X 
 
 
Pain assessment (VAS)27 
 
X 
X 
X 
 
 
Adverse events28 
 
X 
X 
X 
X 
X 
Treatment prescribed for cancer 
management 
 
 
 
 
X 
X 
ECOG PS:  Eastern Cooperative Oncology Group performance status; ECG: electrocardiogram; SO2: oxygen saturation ; 
VAS: visual analogue scale 

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1 Informed consent must be obtained before any procedure is performed.  
2 Relevant medical history (in at least the last 5 years) and current medical conditions will be recorded. 
Special attention will be paid to bleeding disorders. All relevant medications and non-drug therapies 
received by the patient at the screening visit or interrupted within 7 days prior to the procedure will be 
collected.  
3 Data related to diagnosis, disease characteristics and prior treatment in patients with HCC or liver 
metastases will be assessed.  
4 Height, weight and body mass index (BMI) will be assessed at screening. Only weight to calculate BMI 
will be collected at the post-ablation follow-up visits at 1 week, and 1 and 2 months.  
5 Baseline vital signs assessment includes temperature, diastolic and systolic blood pressure, cardiac 
frequency and respiratory frequency. Physical examination, including vital signs, will be carried out 
before ablation of additional tumors (up to 3 ablation sessions) or tumor retreatment is performed. 
6 ECOG PS will be assessed before ablation of additional tumors (up to 3 ablation sessions) or tumor 
retreatment is performed. 
7 For hepatopathy assessment total bilirubin, serum albumin, prothrombin time, ascites (presence/ 
absence), and hepatic encephalopathy (presence/absence) will be evaluated. 
8 12 lead ECG will be only performed during the screening period. In addition, an ECG will be performed 
as a part of the procedures performed before any ablation in case a period of more than 6 months has 
elapsed since the last ECG.   
9 Complete blood count includes hematocrit, hemoglobin, platelets, red blood cells, white blood cells, 
differential counts (basophils, eosinophils, lymphocytes, monocytes, neutrophils, and blasts). The blood 
sample for this assessment must be drawn within the last 7 days before the baseline visit/procedure. In 
case of coincident post-ablation visits (in case of multiple targeted tumors or tumor retreatment), if a 
laboratory test has been performed within the last week as a part of the post-ablation follow-up of a 
tumor, it will not be necessary to repeat this assessment. 
10 Metabolic Panel includes glucose, calcium, sodium, potassium, bicarbonate, chloride, blood urea 
nitrogen (BUN), and creatinine. The blood sample for this assessment must be drawn within the last 7 
days before the baseline visit/procedure. In case of coincident post-ablation visits ((in case of multiple 
targeted tumors or tumor retreatment), if a laboratory test has been performed within the last week as a 
part of the post-ablation follow-up of a tumor, it will not be necessary to repeat this assessment. 
11 Liver panel includes AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, PT and INR. The 
blood sample for this assessment must be drawn within the last 7 days before the baseline visit/ 
procedure. In case of coincident post-ablation visits ((in case of multiple targeted tumors or tumor 
retreatment), if a laboratory test has been performed within the last week as a part of the post-ablation 
follow-up of a tumor, it will not be necessary to repeat this assessment. 
12 Urinalysis examinations including: color, pH, bilirubin, blood, glucose, ketones, protein, and specific 
gravity. The blood sample for this assessment must be drawn within the last 7 days before the baseline 
visit/procedure. In case of coincident post-ablation visits ((in case of multiple targeted tumors or tumor 
retreatment), if a laboratory test has been performed within the last week as a part of the post-ablation 
follow-up of a tumor, it will not be necessary to repeat this assessment. 
13 Immune tests including: CD3+, CD4+, CD8+, CD45+, CD16+, CD56+ and CD19+, C-reactive protein 
(CRP), complement C3, C4 and CH50, immunoglobulins (IgG, IgM, IgA) and IL-6. The blood sample for 
this assessment must be drawn within the last 7 days before the baseline visit/procedure. In case of 
coincident post-ablation visits ((in case of multiple targeted tumors or tumor retreatment), if a laboratory 
test has been performed within the last week as a part of the post-ablation follow-up of a tumor, it will not 
be necessary to repeat this assessment. 
14 Tumor biomarkers: carcinoembryonic antigen (CEA), alfa-fetoprotein (AFP), Cancer Antigens CA15-3 
(Breast Cancer) and CA 19-9 (Pancreatic Cancer) (50, 51). The blood sample for this assessment must 
be drawn within the last 7 days before the baseline visit/procedure. In case of coincident post-ablation 
visits (in case of multiple targeted tumors or tumor retreatment), if a laboratory test has been performed 
within the last week as a part of the post-ablation follow-up of a tumor, it will not be necessary to repeat 
this assessment. The collection of additional samples will only be performed for the first ablation 
performed. In case of multiple targeted tumors or tumor retreatment, additional blood samples with the 
specified purpose will not be collected. 
15 An extra amount of blood will be collected when blood samples are taken for hematology and 
biochemistry evaluation as part of the study assessments. These additional blood samples will be 
centrally processed and stored to be available for additional, originally unforeseen studies and or new 
scientific evidence arises in this field of research. Additional blood samples collected for research 

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purposes will be sent to the central laboratory (Laboratorio de análisis Echevarne, Barcelona, Spain) 
according to the instructions included in the Central Laboratory Sampling Manual provided to the 
investigators. The procedure of blood sample collection, identification of samples (labeling), storage 
conditions, and shipment details will be included in the Central Laboratory Sampling Manual. The 
collection of these additional blood samples is completely voluntary. The patient will be informed about 
the conditions of the collection, storage and use of the additional blood samples and they will not be 
drawn until the patient has given his/her informed consent for this purpose. The patient could give his/her 
consent to participate in the study without authorizing the collection of additional blood samples. 
16 Serum pregnancy test within the last 7 days before the baseline visit.  
17 An imaging assessment on magnetic resonance imaging (MRI) will be performed to determine baseline 
target tumor size (3 perpendicular diameters and volume), number of baseline tumors, location of target 
tumor in the liver segments, and expected ablation volume.  
18 Anesthetic risk of patients before surgery will be assessed at screening and before each ablation 
procedure performed during the study (multiple tumors and/or retreatment of tumors) using the American 
Society of Anesthesiologist score (Appendix 7). 
19 Patient´s quality of life will be assessed using the EORTC QLQ-C30 questionnaire (Appendix 4) at 
baseline and 1 and 2 months post ablation. The questionnaire will be delivered and explained to patients 
by site staff. In case of coincident post-ablation visits ((in case of multiple targeted tumors or tumor 
retreatment), if patient´s quality of life has been assessed using the EORTC QLQ-C30 questionnaire within 
the last week as a part of the post-ablation follow-up of a tumor, it will not be necessary to repeat this 
assessment. 
20 After the procedure, the investigator should collect the following data: procedure date, total duration of 
procedure and total duration of anesthesia time, number and location of tumor(s) ablated, and vital signs 
and SO2 during the procedure. Medications administered and transfusions required will be also collected.  
21 The video recording of the ablation procedure is intended to be performed for all patients participating in 
the study for research purposes and for feedback for engineering improvements. The video recording will 
be performed by the investigator and his collaborators during the ablation procedure at the surgery room of 
the centre. Only the areas restricted to the ablation area will be recorded, avoiding, as far as possible, 
areas of their body by which the patient can be identified (for example tattoos, scars or recognizable 
birthmarks). The video recording of the procedure is totally voluntary. The patient will be informed about 
the conditions of the video recording and it will not be performed until the patient has given his/her 
informed consent for the obtaining and publishing of the video recording of the procedure for research 
purposes. The patient could give his/her consent to participate in the study without authorizing the 
recording of the procedure. 
22 Immediate post-procedure imaging assessments will be performed with ultrasound immediately after the 
ablation to assess the ablation zone and to identify any complications visible on imaging including the 
integrity of vital anatomical structures (major vessels and organs).  
23 Post-procedure imaging assessments on MRI and optional CT or ultrasound with or without contrast one 
day after the procedure: ablation zone assessment. Post-procedure imaging assessments on MRI and 
optional CT or ultrasound with or without contrast 1-week, 1-month and 2-months post-procedure: 
radiological evaluation of tumor coverage according to The International Working Group on Tumor 
Ablation; complications visible on imaging will be identified including the assessment of the integrity of vital 
anatomical structures (major vessels and organs). The images (MRI and optional CT) will be sent to a 
central reader, expected to be the Department of Radiology of the University of Wisconsin, United States) 
for central reading and analysis. In case of coincident post-ablation visits ((in case of multiple targeted 
tumors or tumor retreatment), if the imaging assessment has been performed within the last week as a part 
of the post-ablation follow-up of a tumor, it will not be necessary to repeat this assessment. 
24 Ablation zone involution assessments will be performed according to the International Working Group on 
Tumor ablation criteria.  
25 Medications administered during the 24-hour period post-procedure, including analgesics for post-
operative pain, and/or anticoagulants will be collected. All new medications administered or the changes in 
prior treatment received by the patient will be recorded.  
26 Blood product transfusion required during the 24 hours period post-procedure and during the 1-week 
post-procedure period will be recorded.  
27 The potential occurrence of pain post-ablation will be assessed using a 0 to 100 mm VAS visual analog 
scale (VAS), where 0 is “no pain” and 100 is “the maximum pain possible”. Patients will have to mark the 
level of their pain on the VAS before the ablation procedure, within the 24 hour period post-procedure and 
one week after the procedure. The requirement of analgesic treatment will be also recorded at the same 
time when the pain assessment (VAS) is conducted (Appendix 5).  

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28 All adverse events experienced by patients will be captured from the time the informed consent is signed 
until the end of the study and will be recorded in the CRF. In addition, all SAEs occurring during use of the 
VORTX Rx and after the procedure through the end of the study will be reported to the sponsor according 
to the guidelines specified in section 9.4.1 of this investigational plan.  
29 This visit may coincide with post-ablation follow-up of other tumor ablated during the study. 
30 This visit may coincide with post-ablation follow-up of other tumor ablated during the study.  
 
5.4.1 SCREENING (DAY -60 TO DAY 0) 
During the screening period, potential candidates will be provided with the information 
concerning the study and the patient information sheet along with the informed consent form 
(ICF). Before any study specific procedures are conducted, informed consent must be obtained, 
in writing or orally in front of a witness who is independent of the investigator team. No patient 
will be included in the study until being appropriately informed by the investigator and having 
provided their informed consent to participate in the study. 
Once the informed consent has been obtained, the investigator can proceed with collecting data 
from the consented individual’s medical record and conduct the evaluations required to 
determine eligibility of the patient for potential participation in this study. These evaluations will 
be conducted within the 2-month period prior to the procedure. During the screening period 
(days -60 to 1), it must be confirmed that the patient meets all selection criteria for study 
participation based on the procedures conducted during this period. Patients will be scheduled 
for the procedure (baseline visit) by site staff.  
Patients who sign an informed consent but fail to undergo an ablation for any reason will be 
considered a screening failure. The reason for not being enrolled will be entered on the 
screening log and each patient’s demographic information and date of screening failure will be 
recorded at the screening failure log. 
Patient information to be collected at screening will include: 
 
Demographic data: age, gender and race. 
 
Relevant medical history (in at least the last 5 years) and current medical conditions. 
Special attention will be paid to bleeding disorders.  
 
All relevant medications and non-drug therapies received by the patient at the screening 
visit or interrupted within 7 days prior to the procedure must be reported in the eCRF. 
o 
Patients receiving warfarin, clopidogrel, or any other long-acting anticoagulants 
must discontinue these agents at least two weeks prior to the scheduled 
procedure.  
o 
Warfarin patients should have INR draw within the last 7 days prior to the 
ablation showing INR <2.0 and platelets >50 x 109/L.  
o 
Patients receiving immunotherapies must discontinue these agents 4 weeks 
prior to the scheduled procedure.  
 
Data to be collected related to liver tumors:  
o 
Liver Metastases:  
 
Primary tumor:  
 
Date of diagnosis 
 
Disease stage (Tumor/node/metastasis [TNM] classification) at 
diagnosis 
 
Location: e.g. colon, rectum, colon and rectum, breast or 
pancreas. 

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 
Surgery: yes/no, date, technique 
 
Neoadjuvant and/or adjuvant treatment: yes/no, start date and 
completion of treatment 
 
Adjuvant radiotherapy: yes/no, start and end date 
 
Metastatic disease: 
 
Date of diagnosis  
 
Disease stage (TNM classification).  
 
Tumor disease presentation: synchronous, metachronous 
 
Number of metastatic sites.  
 
Metastases 
location: 
liver-only 
metastases, 
extrahepatic 
disease (lung, etc.). 
 
Number and size (maximum diameter) of tumors.  
 
Location of tumors in the liver segments. 
 
Prior liver metastases ablation: yes/no 
o Date of ablation 
o Technique used: radiofrequency ablation (RFA), HIFU, 
Microwave (MWA), Cryo, etc.  
o Tumor ablated: size, location (liver segment).  
o Ablation result: complete or incomplete ablation 
 
Prior liver metastases resection: yes/no 
o Date of surgery 
o Technique used: one-stage or two-stage hepatectomy, 
portal vein embolization, etc.   
o Number of metastases resected: number, location (liver 
segment).  
o Resection rate: complete resection (R0), incomplete 
resection (R1), not evaluable.  
o Complications after liver resection.  
o Neoadjuvant treatment: yes/no, treatment received 
(chemotherapy, targeted therapy).  
o Adjuvant 
therapy: 
yes/no, 
treatment 
received 
(chemotherapy, targeted therapy, radiotherapy). 
 
First-, second-, or further line of treatment received for 
metastatic disease: start and end date, type, number of cycles 
administered (if applicable), and response to last treatment 
(last tumor assessment).  
 
HCC:  
 
Date of diagnosis. 
 
Disease stage TNM classification/Barcelona-Clinic Liver Cancer 
(BCLC) staging. 
 
Number and size of tumors.  
 
Location of tumors in the liver segments. 
 
Surgery: yes/no, date, technique used. 

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 
Prior liver ablation: yes/no 
o Date of ablation 
o Technique used: RFA, HIFU, MWA, Cryo etc.  
o Tumors ablated: size, location.  
o Ablation result: complete or incomplete ablation 
 
Prior chemotherapy: yes/no 
o Start and end date, number of cycles administered. 
 
Prior intra-arterial treatments: yes/no 
o Type (TACE, Y90, intra-arterial chemotherapy), date.   
The following will be conducted to further assess eligibility: 
 
Physical examination. 
 
Vital signs: temperature, diastolic and systolic blood pressure, cardiac frequency and 
respiratory frequency.  
 
Height, weight and body mass index (BMI). 
 
ECOG performance status (Appendix 6). 
 
Child-Pugh score for hepatopathy assessment (total bilirubin, serum albumin, 
prothrombin 
time, 
ascites 
[presence/absence], 
hepatic 
encephalopathy 
[presence/absence]) and category (A, B, or C). Child-Pugh scoring should be conducted 
in the 7-14 day period before the ablation procedure day. 
 
Liver volume reserve (%) measured by CT. 
 
Standard 12 lead electrocardiogram (ECG). 
 
Baseline imaging to determine the baseline target tumors according to the criteria of the 
International Working Group on Tumor Ablation (42, 45): 
o 
Technique used: MRI (optional CT or ultrasound with or without contrast 
imaging at discretion of Investigator).  
o 
The images (MRI and optional CT) will be sent to a central reader, the 
Department of Radiology of the University of Wisconsin School of Medicine and 
Public Health (Wisconsin, United States), for central reading and analysis.  
 
Assessment of liver tumor or liver metastases by MRI (within the last 14 days prior to 
baseline visit/ablation procedure): 
o 
Baseline target tumor size (diameter in 3 perpendicular dimensions and 
volume).  
o 
Number of baseline tumors identified (confirmatory assessment). 
o 
Location of baseline tumors in the liver segments (confirmatory assessment). 
o 
Assessment of the expected ablation volume.  
 
Procedure simulation (within the last 14 days prior to baseline visit/ablation procedure): 
o 
Using the ultrasound imaging capabilities of the VORTX Rx® system, a 
simulation of the ablation procedure will be conducted within the one-week 
period prior to the planned procedure to confirm the ability of the VORTX Rx® 
system to visualize the target tumor.  Site staff should inform patients to come 
to the clinic for the simulation after an overnight fast of at least 8 hours. 
o 
The expected PAV will be assessed by the investigator using the ultrasound 
imaging of the VORTX Rx® at the session of the procedure simulation.  

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 
Laboratory evaluations (within the last 7 days prior to baseline visit/procedure) as 
follows: 
Note: Site staff should inform subjects to come to the clinic after an overnight fast of at 
least 8 hours on the day that blood will be drawn for laboratory assessments.  
o 
Complete blood count (CBC): Hematocrit, hemoglobin, platelets, red blood 
cells, white blood cells, differential counts (basophils, eosinophils, lymphocytes, 
monocytes, neutrophils, and blasts). 
o 
Metabolic panel: glucose, calcium, sodium, potassium, bicarbonate, chloride, 
blood urea nitrogen (BUN), creatinine.  
o 
Liver panel: AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, TP 
and INR. 
o 
Urinary analysis: color, pH, bilirubin, blood, glucose, ketones, protein, and 
specific gravity. 
o 
Immunologic parameters blood test including:  
 
Lymphocyte subset panel: CD3+ (T cells), CD4+ (T helper cells), CD8+ 
(T suppressor/cytotoxic cells), CD45+ (leucocyte common antigen), 
CD16+, CD56+ (NKT cells) and CD19+ (B-lymphocyte antigen.  
 
C-reactive protein (CRP) 
 
Complement C3, C4 and CH50 
 
Immunoglobulins (IgG, IgM, IgA) 
 
Interleukin 6 (IL-6)  
o 
Tumor biomarkers: carcinoembryonic antigen (CEA), alfa-fetoprotein (AFP), 
Cancer Antigens CA15-3 (Breast Cancer) and CA 19-9 (Pancreatic Cancer) 
(50, 51). 
o 
Blood samples and urine samples obtained will be sent to the central laboratory 
(Laboratorio de análisis Echevarne, Barcelona, Spain).  
o 
An extra amount of blood will be collected when blood samples are taken for 
hematology and biochemistry evaluation as part of the study assessments. 
These additional blood samples will be centrally processed and stored to be 
available for additional, originally unforeseen studies and or new scientific 
evidence arises in this field of research. Additional blood samples collected will 
be sent (along with the blood samples and urine samples for study 
assessments) to the central laboratory where these samples will be preserved 
for up to three years for future testing as related to this study or future scientific 
discoveries of the subject’s medical condition. The procedure of blood sample 
collection, identification of samples (labeling), storage conditions, and shipment 
details will be included in the Central Laboratory Sampling Manual which will be 
provided to the investigators.  
 
Serum pregnancy test performed within the last 7 days before the baseline 
visit/procedure.  
 
American Society of Anesthesiologist score for anesthetic risk assessment (Appendix 
7).  
 
Quality of life assessment using the EORTC QLQ-C30 questionnaire (Appendix 4).  
After completion of all procedures required for subject selection and the subject has been 
determined to be eligible for the procedure, the investigator/site staff will schedule the procedure 
and inform the subject to fast at least 8 hours prior to arriving to the site the day that the ablation 
is scheduled. 

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5.4.2 VISIT 1: VORTX RX ABLATION PROCEDURE 
The investigator must confirm that all the inclusion and none of the exclusion criteria are met the 
day of the procedure.  
Pain assessment must be undertaken. Patients will have to mark the level of their pain on the 
VAS (Appendix 5) before the ablation procedure.   
Data related to the procedure and immediate post-ablation data will be collected: 
 
Date of procedure.  
 
Total duration of ablation procedure and total duration of anesthesia.  
 
Number and size of tumors ablated during the procedure. 
 
Ablated tumor(s) location: proximity to vital structures (near blood vessels or gallbladder 
or containing blood vessels or gallbladder [yes/no]).  
 
Vital signs during ablation and oxygen saturation (SO2).   
 
AEs: complications during ablation and immediate post-procedural complications.  
o 
In addition to the recording of AEs in the CRF, the SAEs must be reported as 
outlined in the section 9.4.1.  
 
Medications administered after ablation (if any).  
 
Transfusion required after ablation: yes/no.  
 
5.4.3 VISIT 2: 24 HOURS POST-ABLATION 
 
Physical examination, including vital signs.   
 
Laboratory tests (after an overnight fast of at least 8 hours):  
o 
CBC: hematocrit, hemoglobin, platelets, red blood cells, white blood cells, 
differential counts.  
o 
Metabolic Panel: glucose, calcium, sodium, potassium, bicarbonate, chloride, 
BUN, creatinine.  
o 
Liver panel: AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, PT 
and INR. 
o 
Immunologic parameters blood test.  
o 
Tumor biomarker blood test. 
o 
Urinalysis: color, pH, bilirubin, blood, glucose, ketones, protein, myoglobin, and 
specific gravity.  
o 
Blood samples and urine samples obtained will be sent to the central laboratory 
(Laboratorio de análisis Echevarne, Barcelona, Spain).  
o 
Additional blood samples will be drawn and sent to the central laboratory for 
future testing. 
 
Assess Child-Pugh score.  
 
Post procedure imaging using MRI; optional CT or ultrasound with or without contrast 
imaging at Investigator discretion: 
o 
Assessment of the ablation zone after the procedure by the central reader: 
actual ablation zone compared with planned ablation volume (component of 
success criteria).  

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o 
Complications visible on imaging including assessment of the integrity of vital 
anatomical structures (major vessels and organs).  
o 
The images (MRI and optional CT) will be sent to central reader (Department of 
Radiology of the University of Wisconsin School of Medicine and Public Health, 
Wisconsin, United States), for central reading and analysis. 
 
Assessment of AEs occurred within 24 hours post-ablation. 
o 
In addition to the recording of AEs in the CRF, the SAEs must be reported as 
outlined in the section 9.4.1.  
 
Pain assessment by a VAS (Appendix 5).   
 
Medications administered during the 24-hour period post-procedure, including 
analgesics (drugs and doses) for post-operative pain, and/or anticoagulants. 
 
Blood transfusion requirement: yes/no.  
 
5.4.4 VISIT 3: ONE WEEK POST-ABLATION 
 
Hospitalization duration.  
 
Physical examination, including BMI, and vital signs.  
 
ECOG PS.  
 
Laboratory test (Site staff should inform patients to come to the clinic after an overnight 
fast of at least 8 hours on the day that the blood will be drawn for laboratory 
evaluations):  
o 
CBC: hematocrit, hemoglobin, platelets, red blood cells, white blood cells, 
differential counts.  
o 
Metabolic Panel: glucose, calcium, sodium, potassium, bicarbonate, chloride, 
BUN, creatinine.  
o 
Liver panel: AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, PT 
and INR. 
o 
Urinalysis: color, pH, bilirubin, blood, glucose, ketones, protein, myoglobin, and 
specific gravity.  
o 
Immunologic parameters blood test. 
o 
Tumor biomarkers blood test. 
o 
Blood samples and urine samples obtained will be sent to the central laboratory.  
o 
Additional blood samples will be drawn and sent to the central laboratory for 
future testing. 
 
Assess Child-Pugh score 
 
Imaging assessment using MRI and optional CT or ultrasound with or without contrast 
imaging: 
o 
Assessment of the ablation zone to evaluate tumor coverage.   
o 
Evaluation of the ablation zone involution. 
o 
Complications visible on imaging including assessment of the integrity of vital 
anatomical structures (major vessels and organs).  
o 
The images (MRI and optional CT or ultrasound with or without contrast 
imaging) will be sent to central reader, expected to be the Department of 
Radiology of the University of Wisconsin School of Medicine and Public Health 
(Wisconsin, United States), for central reading and analysis. 

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 
Pain assessment by a visual analog scale (VAS) (Appendix 5).   
 
Relevant medications received.  
 
Blood transfusion requirement: yes/no. 
 
Assessment of the evolution of AEs (if any) and AEs occurred since last visit. 
o 
In addition to the recording of AEs in the CRF, the SAEs must be reported as 
outlined in the section 9.4.1.  
 
5.4.5 VISIT 4: ONE MONTH POST-ABLATION 
 
Physical examination: BMI, vital signs. 
 
ECOG PS. 
 
Laboratory test (Site staff should inform patients to come to the clinic after an overnight 
fast of at least 8 hours on the day that the blood will be drawn for laboratory 
evaluations):  
o 
CBC: hematocrit, hemoglobin, platelets, red blood cells, white blood cells, 
differential counts.  
o 
Metabolic Panel: glucose, calcium, sodium, potassium, bicarbonate, chloride, 
BUN, creatinine.  
o 
Liver panel: AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, PT 
and INR. 
o 
Urinalysis: color, pH, bilirubin, blood, glucose, ketones, protein, myoglobin, and 
specific gravity.  
o 
Immunologic parameters blood test.  
o 
Tumor biomarkers blood test. 
o 
Blood samples and urine samples obtained will be sent to the central laboratory.  
o 
In case of coincident post-ablation visits (in case of multiple ablation sessions), 
if a laboratory test has been performed within the last week as a part of the 
post-ablation follow-up of a tumor (combination of tumors ablated in the same 
session), it will not be necessary to repeat this assessment. 
o 
Additional blood samples will be drawn and sent to the central laboratory for 
future testing. 
 
Assess Child-Pugh score 
 
Imaging assessment using MRI and optional CT or ultrasound with or without contrast 
imaging: 
o 
Assessment of the ablation zone to evaluate tumor coverage.   
o 
Evaluation of the ablation zone involution as measured by comparative 3 
dimensional (3D) images. 
o 
Complications visible on imaging including assessment of the integrity of vital 
anatomical structures (major vessels and organs).  
o 
The images (MRI and optional CT or ultrasound with or without contrast 
imaging) will be sent to central reader for central reading and analysis. 
o 
In case of coincident monthly post-ablation visits (in case of multiple ablation 
sessions), if the imaging assessment has been performed within the last week 
as a part of the post-ablation follow-up of a tumor (combination of tumors 
ablated in the same session), it will not be necessary to repeat this assessment.  
 
Relevant treatment received 

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o 
Treatment prescribed for cancer management: any antineoplastic treatment 
required by the patient, including chemotherapy or targeted biological therapies, 
will be recorded.  
 
Assessment of the evolution of complications (if any) and AEs occurred since last visit. 
o 
In addition to the recording of AEs in the CRF, the SAEs must be reported as 
outlined in the section 9.4.1.  
 
Quality of life assessment using the EORTC QLQ-C30 questionnaire (Appendix 4).  
In case of coincident post-ablation visits (in case of multiple ablation sessions), if 
patient´s quality of life has been assessed using the EORTC QLQ-C30 questionnaire 
within the last week as a part of the post-ablation follow-up of a tumor, it will not be 
necessary to repeat this assessment. 
 
5.4.6 VISIT 5: TWO MONTHS POST-ABLATION 
 
Physical examination: BMI, vital signs. 
 
ECOG PS.  
 
Laboratory test (Site staff should inform patients to come to the clinic after an overnight 
fast of at least 8 hours on the day that the blood will be drawn for laboratory 
evaluations):  
o 
CBC: hematocrit, hemoglobin, platelets, red blood cells, white blood cells, 
differential counts.  
o 
Metabolic Panel: glucose, calcium, sodium, potassium, bicarbonate, chloride, 
BUN, creatinine.  
o 
Liver panel: AST, ALT, alkaline phosphatase, albumin and bilirubin, GGT, PT 
and INR. 
o 
Urinalysis: color, pH, bilirubin, blood, glucose, ketones, protein, myoglobin, and 
specific gravity.  
o 
Immunologic parameters blood test. 
o 
Tumor biomarkers blood test. 
o 
Blood samples and urine samples obtained will be sent to the central laboratory. 
o 
 In case of coincident post-ablation visits (in case of multiple ablation sessions), 
if a laboratory test has been performed within the last week as a part of the 
post-ablation follow-up of a tumor (or combinations of tumors ablated in the 
same session), it will not be necessary to repeat this assessment. 
o 
Additional blood samples will be drawn and sent to the central laboratory for 
future testing. 
 
Assess Child-Pugh score 
 
Imaging assessment using MRI and optional CT or ultrasound with or without contrast 
imaging: 
o 
Assessment of the ablation zone to evaluate tumor coverage.   
o 
Evaluation of the ablation zone involution. 
o 
Complications visible on imaging including assessment of the integrity of vital 
anatomical structures (major vessels and organs). 
o 
The images (MRI and optional CT or ultrasound with or without contrast 
imaging) will be sent to central reader for central reading and analysis. 
o 
In case of coincident monthly post-ablation visits (in case of multiple ablation 
sessions), if the imaging assessment has been performed within the last week 

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as a part of the post-ablation follow-up of a tumor (or combinations of tumors 
ablated in the same session), it will not be necessary to repeat this assessment. 
 
Relevant treatment received:  
o 
Treatment prescribed for cancer management: any antineoplastic treatment 
required by the patient, including chemotherapy or targeted biological therapies, 
will be recorded.  
 
Assessment of the evolution of complications (if any) and AEs occurred since last visit. 
o 
In addition to the recording of AEs in the CRF, the SAEs must be reported as 
outlined in the section 9.4.1.  
 
Quality of life assessment using the EORTC QLQ-C30 questionnaire (Appendix 4).  
In case of coincident post-ablation visits (in case of multiple ablation sessions), if 
patient´s quality of life has been assessed using the EORTC QLQ-C30 questionnaire 
within the last week as a part of the post-ablation follow-up of a tumor, it will not be 
necessary to repeat this assessment. 
 
5.4.7 END OF THE STUDY OR TERMINATION  
The end of study (at data closure after last patient last visit (LPLV)) will occur after all subjects in 
the study have completed their last assessment as per protocol. 
The study can be terminated at any time for any reason by the Sponsor or regulatory authorities 
when there were risks for subjects or other reasons that justify such a decision. A participating 
site can be closed when there is evidence of non-compliance with this study protocol. Both the 
Sponsor and investigator will have the right to early terminate the study at any moment. Should 
this occur they both will revise and decide the procedures to follow in each case, due 
consideration will be taken to the protection of subjects participating in the study. The 
investigator may be informed of additional procedures to be followed in order to ensure that 
adequate consideration is given to the protection of the subjects’ interests. The sponsor will be 
responsible for informing the CEIm (for its initials in Spanish, Comité Ético de la Investigación 
con medicamentos) of the early termination of the trial. 
 
6 
ABLATION  
6.1 MEDICAL DEVICE 
6.1.1 MEDICAL DEVICE OVERVIEW 
Investigational medical device: VORTX Rx®  
The VORTX Rx® is a platform device for non-invasive, non-thermal, image-guided histotripsy 
ablation delivery. The system as configured is a portable device designed to treat soft tissues 
using very low duty cycle ultrasound pulses from outside the patient’s body. The low duty cycle 
refers to the fact that the microsecond histotripsy pulses are only on approximately 1% of the 
time. These pulses form an acoustic cavitation bubble cloud at the focal area which 
mechanically destroys the cellular structure of the soft tissue with no remaining intact cells. The 
bubble cloud is positioned in the tissue of the liver by the clinician.  
The VORTX Rx® ultrasound system is a mobile (AC-powered) designed to treat soft tissue (e.g., 
liver) through the extracorporeal application of high intensity focused ultrasound. It consists of a 

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high frequency ultrasound therapy transducer (generator), a micro-positioner, an Ultrasound 
Medium Coupler (UMC) bowl to provide a water coupling (e.g. degassed water and chilling 
probe) and 3M Ioban™ drape, a hand-held imaging probe (e.g., a piezoelectric transducer), 
operator's console (cart), monitoring systems, e-stop button, software, and a foot-switch. See 
figure below (Figure 2) or the User Manual for further details.  
This device is for Investigational Purposes Only and will NOT be CE Marked. The proposed 
conformity assessment of the VORTX RX® System is a Class IIb, rule 9 device according to 
Annex IX of the Council Directive 93/42/EEC, The device rules include administration of energy 
in a potentially hazardous way (VORTX RX primary mode of action is to ablate soft tissue 
through mechanical focused ultrasound cavitation). It is an active, non-implantable medical 
device. The device has software controls. None of the special rules (rules 13 to 18) apply.  
 
Figure 2. VORTX Rx® system 
 
1 
Therapy Transducer  
2 
Imaging Probe 
3 
Console & Micropositioner Control (Software) 
4 
Ultrasound Medium Container (UMC): bowl, non-sterile 3M Ioban™ drape & holder  
5 
Micropositioner 
6 
Cart and Arm         
7 
Coupling Medium (degassed water container)  
8 
Laser Alignment Tool & Positioning Tool 

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6.2 ABLATION PROCEDURE USING THE VORTX RX  
The study investigator will be fully trained on the VORTX Rx® device and will be supported 
during the procedure by qualified and trained engineering personnel from HistoSonics, Inc. Site 
personnel will be qualified and trained prior to the study. A copy of the User Manual will be 
provided to the site personnel.  
Within 7-14 days prior to the procedure day, MRI imaging of the targeted tumor will be 
conducted to identify the location and dimensions of the targeted tumor(s). In addition, within a 
week prior to each ablation procedure, a procedure simulation will be carried out using VORTX 
Rx® ultrasound imaging of the liver to assess the targeted tumor(s) prior to the procedure to 
ensure adequate and clear visualization using ultrasound-image guidance.  
Patients will be admitted to the hospital for the procedure. The ablation will be performed in the 
surgery room of the center(s). Patients will be placed under general anesthesia to reduce 
patient discomfort and provide for investigator complete control, including patient breathing and 
motion during the procedure.  
The ablation will be performed using the initial system settings determined by pre-clinical 
studies, as detailed in the User Manual. Prior to the procedure, the device will perform a system 
check on itself (not involving a patient) to ensure device performance and alignment of the 
bubble cloud to the focal position of the therapy transducer. The therapy transducer with co-
axially aligned ultrasound imager will then be coupled to the patient’s chest or abdomen using 
the ultrasound medium coupling device (UMC), which will be applied to the patient. The 
investigator will use the mechanical arm to grossly position the therapy transducer to the center 
of the targeted tumor volume. Once the center of the tumor has been identified on ultrasound 
imaging, the investigator will lock the arm in place to fix the position of the therapy transducer 
for pre-ablation planning.  
Prior to starting the ablation, the investigator will use the system software to align the target 
tissue contours and margin contours to cover the entire target region. Once these parameters 
are set, the investigator will scan through the PAV using the system micro-positioner in order to 
verify that the target contour diameters match the desired target in every imaging plane. The 
investigator can then make minor adjustments to the plan as needed, prior to proceeding to the 
ablation test pulse stage of the workflow.  
Once the investigator has confirmed the treatment plan, a test pulse will be delivered in order to 
generate a bubble cloud at the center of the tumor. To accomplish this, the investigator will 
adjust the therapy system output until a bubble cloud is achieved and sustained at the focus. 
The investigator will confirm that the bubble cloud location matches the expected ablation 
location (i.e. crosshairs) and make any minor modifications to the crosshairs as needed. Once 
test pulse energy has been applied, the subject will be considered enrolled.   
After successful completion of the test pulse, the investigator will move to the treatment stage of 
the workflow and initiate the ablation. In this process, the system will mechanically scan through 
the entire targeted volume within the contours, including the margin, set during the planning 
stage. During ablation, the investigator will monitor the procedure using real-time ultrasound 
imaging to ensure the bubble cloud remains in the expected location in the target throughout the 
procedure. The system provides visual indicators of treated and untreated points during the 
procedure. The investigator will have the ability to visualize the need to stop and restart the 
ablation at any time, such as to correct for any unexpected motion or mis-alignment of the 
bubble cloud that may occur.  
After the entire ablation is finished, the investigator will review the ablated zone using ultrasound 
imaging to determine if any further ablation is required. The investigator will then confirm the 
ablation is completed and remove the therapy system from the patient. The overall procedure 

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time is expected to last less than 4 hours. After the procedure, patients are expected to be 
hospitalized for up to 24 hours. They will be discharged within 24 hours whenever patients have 
not experienced any complication requiring extended hospitalization. 
More details on the procedure to be performed using the investigational device is provided in 
the IB.  
6.3 MEANS OF SUPPLY OF THE MEDICAL DEVICE 
The VORTX Rx® medical device used in this study will be supplied by HistoSonics, Inc. (Ann 
Arbor, Michigan, USA). This is an investigational device that is a not CE-marked and will be 
imported into the European Union using an importation company dedicated to that purpose.  
7 
CONCOMITANT MEDICATIONS 
All medications and non-drug therapies (including blood transfusions) administered during the 
study will be listed in the eCRF. The generic drug name, the reason for prescription, and the 
initiation and completion dates will be recorded.  
The patient will be told to notify the investigator about any new medications he/she takes during 
the study.  
7.1 PERMITTED CONCOMITANT MEDICATIONS 
The use of any medication needed by patients for proper clinical management is allowed at the 
discretion of the investigator, with the exception of those detailed in section 7.2 whose use 
would require patient´s withdrawal.  
Chemotherapy and targeted therapies are allowed to be used during the study provided that a 
one month period has elapsed since the ablation was performed. In addition, a subsequent 
ablation may be performed 2 weeks after chemotherapy completion/discontinuation and after 4 
weeks following any targeted treatment completion. A maximum of 3 treatments (chemotherapy 
or targeted therapies) will be allowed during the patient follow up. Each treatment received by 
the patient during his/her participation in the study will be restricted to the timing specified per 
protocol (minimum 1 month between ablation procedures, minimum 2 weeks post any 
chemotherapy with said chemotherapy not to begin before 1 month post any ablation) (Figure 
3).  

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Figure 3. Chemotherapy and/or targeted therapy administration  
ABLATION
1 month
2 weeks
Chemotherapy
CHEMO 
INITIATION
CHEMO 
DISCONTINUATION
Time on treatment upon
investigator discretion
ABLATION
ABLATION
1 month
4 weeks
Targeted therapy
TARGETED 
TREATMENT 
INITIATION
TARGETED 
TREATMENT 
DISCONTINUATION
Time on treatment upon
investigator discretion
ABLATION
 
 
The use of analgesics for pain is allowed after ablation whenever these agents are prescribed 
by the investigator. The use of analgesics during the study will be recorded in the eCRF. 
7.2 PROHIBITED CONCOMITANT MEDICATIONS/INTERVENTIONS 
The following medications are prohibited during the study: 
 
Any investigational drug administration or use of any investigational medical device. 
 
Clopidogrel and warfarin or any other long-acting anticoagulants.  
8 
ASSESSMENTS 
8.1 ABLATION ASSESSMENTS 
Radiologic evaluation of the ablation zone will be conducted according to The International 
Working Group on Image-guided Tumor Ablation (42, 45) to determine technical success 
(primary endpoint) 1 day after the ablation procedure and to evaluate local tumor progression 
and involution of the ablation zone on each subsequent follow-up visit (1 week and 1 and 2 
months post-ablation).  
Post-ablation imaging will utilize contrast-enhanced dynamic MRI using a 1.5T MR scanner with 
maximum slice thickness of 5 mm. Optional contrast-enhanced multidetector CT, with at least 
64 slices and a maximum slice thickness of 5 mm or ultrasound with or without contrast, may be 
used at investigator discretion. The same technique used for evaluation of target tumors for 
patient selection (baseline evaluation prior the procedure) will be used for evaluation of the 
ablation zone. Both MRI and optional CT imaging modalities will be performed with pre- and 
post-dynamic intravenous contrast enhancement. MRI is the primary modality for imaging 
follow-up, given that this technique provides excellent soft tissue resolution with multiplanar 
imaging capability and lacks ionizing radiation. However, if a contraindication so warrants or if 
additional data is desired, CT or ultrasound with or without contrast imaging may be performed 
in some cases at the discretion of the Investigator. 

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Radiologic evaluation of acute technical success and the ablation zone progression during the 
study will be conducted by an independent central-reader radiologist. All images (MRI and CT) 
will be sent through the eCRF or other common secured imaging portal or via secure media to a 
central reader, expected to be the Department of Radiology of the University of Wisconsin 
School of Medicine and Public Health (Wisconsin, United States), where the data sets will be 
analyzed.  
8.1.1  TECHNICAL PERFORMANCE ASSESSMENTS 
Acute technical performance will be evaluated on the basis of technical success of each tumor 
ablation assessed by contrast enhanced MRI 1-day post-procedure.  
Technical success of the ablation is defined as the ability of the investigational device to 
generate an ablation zone per the PAV (a three-dimensional volume defined by the investigator 
using the VORTX Rx® in the planning phase of the software workflow). Technical success will 
be determined by assessing if the post-procedure ablation zone corresponds to the PAV, as 
measured by a multi-dimensional measurement of the 1-day post-procedure ablation zone and 
characterized qualitatively in the radiological report. The acute technical success of up to 3 
separate tumor ablations in any individual patient will be assessed.  
8.1.2 TUMOR PROGRESSION ASSESSMENT 
Local tumor progression will be assessed by radiological evaluation according to the 
International Working Group on Image-guided Tumor Ablation Group at 1-week, 1-month and 2-
months post-ablation.  
Local tumor progression is defined as the appearance of tumor foci at the edge of the ablation 
zone after ablation has been achieved.  
Baseline imaging will be used to obtain measurements of the target tumor and will be used as a 
comparator to the ablation zone at follow-up imaging time points. 
8.1.3 INVOLUTION OF THE ABLATION ZONE 
Involution of the ablation zone during the study will be assessed by the radiological evaluation 
of the ablation zone at 1-week, 1-month and 2-months post-ablation.  The 1-day post-procedure 
MRI will serve as the baseline for the radiological evaluation of the involution of the ablation 
zone. 
8.2 SAFETY ASSESSMENTS 
Safety will be monitored by assessing and collecting AEs, SAEs, laboratory evaluations, 
physical examinations, vital signs, ECOG performance status, ECG, and imaging studies.  
Safety will be evaluated from the point of ablation initiation (first ablation performed) through to 
each post-ablation follow-up visits during patient participation. The investigator will assess the 
appearance of AEs from procedure initiation and will record it in the eCRF, together with 
concomitant medications and/or blood product transfusions received over this time and any 
antineoplastic therapies used through study completion.  
An independent DSMB will be used for review of safety data to provide advice to the sponsor 
regarding actions the board recommends to ensure the safety, protection and well-being of the 
subjects enrolled in the study. Additional details regarding the structure of the DSMB is provided 
in Section 9.5. 
For details on AE collection and reporting, refer to Section 9.4. 

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8.2.1 PHYSICAL EXAMINATION 
A physical examination will be performed at screening (and before any ablation procedure 
performed) and at every follow-up visits. It will include the examination of general appearance 
and body systems as indicated by patient symptoms, AEs, or any other findings.  
Significant findings that were present prior to the signing of informed consent must be included 
in the eCRF. Significant new findings that begin or worsen after informed consent is signed 
must be recorded as AEs in the eCRF. 
8.2.2 VITAL SIGNS 
Vital signs will be collected in all study visits. Vital signs will be taken with the patient in the 
sitting position after 5 minutes of rest. 
8.2.3 HEIGHT AND WEIGHT 
Height in centimeters (cm) will be measured only at screening. Body weight in kilograms (to the 
nearest 0.1 kilogram [kg] in indoor clothing, but without shoes) will be measured during the 
screening visit and at subsequent follow-up visits to assess BMI. 
8.2.4 ECOG PERFORMANCE STATUS 
The performance status will be assessed according to the ECOG performance status at 
screening, and at post-ablation follow-up visits 1 week, 1 and 2 months post-ablation. 
The ECOG performance status is graded on a 6-point scale that ranges from 0 to 5 (Appendix 
6). 
8.2.5 LABORATORY EVALUATIONS 
All laboratory assessments will be performed at a central qualified laboratory. Site staff should 
inform patients to come to the clinic after an overnight fast of at least 8 hours on the day that the 
blood will be drawn for laboratory evaluations.  
In case of coincident post-ablation visits when more than one ablation procedure has been 
performed, it will not be necessary to repeat the laboratory test if this assessment has been 
performed within the last week as a part of the post-ablation follow-up of a tumor. 
 
Table 2. Local clinical laboratory parameters collection plan 
Test  
Parameters to be tested 
Visit 
Complete blood count 
Hematocrit, hemoglobin, platelets, red blood cells, 
white blood cells, differential counts (basophils, 
eosinophils, lymphocytes, monocytes, neutrophils, 
and % of blasts). 
During 
the 
screening 
period (7 days before the 
baseline visit) and at 
every follow-up visit (1 
day, 1 week and 1 and 2 
months post-ablation).  
Chemistry  
Sodium, potassium, calcium, chloride, bicarbonate, 
glucose, total protein, BUN, creatinine, alkaline 
phosphatase, ALT (SGPT), AST (SGOT), GGT, 
albumin, total bilirubin   
During 
the 
screening 
period (7 days before the 
baseline visit) and at 
every follow-up visit (1 
day, 1 week and 1 and 2 
months post-ablation). 
Coagulation 
PT, PTT and INR. 
During 
the 
screening 
period (7 days before the 

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baseline visit) and at 
every follow-up visit (1 
day, 1 week and 1 and 2 
months post-ablation). 
Immune tests 
Lymphocyte subset panel: CD3+ (T cells), CD4+ (T 
helper cells), CD8+ (T suppressor/cytotoxic cells), 
CD45+ (leucocyte common antigen), CD16+, 
CD56+ (NKT cells) and CD19+ (B-lymphocyte 
antigen), CRP, complement C3, C4 and CH56, 
immunoglobulins (IgG, IgM, IgA) and IL-6. 
At screening (7 days 
before the baseline visit) 
and at every follow-up 
visits performed, 1 day, 1 
week, 1 and 2 months 
post-ablation. 
Urinalysis 
Dipstick urinalysis. 
Macroscopic panel: color, pH, bilirubin, blood, 
glucose, ketones, protein, and specific gravity. 
During 
the 
screening 
period (7 days before the 
baseline visit) and at 
every follow-up visit (1 
day, 1 week and 1 and 2 
months post-ablation). 
Pregnancy test 
Serum pregnancy test. 
During 
the 
screening 
period (within the last 14 
days before the baseline 
visit) and at any moment 
if necessary.  
Other laboratory 
analysis 
Not applicable 
Not applicable 
Tumor biomarkers  
Carcinoembryonic antigen (CEA), alfa-fetoprotein 
(AFP), Cancer Antigens CA15-3 (Breast Cancer) 
and CA 19-9 (Pancreatic Cancer) (50, 51) 
At screening (7 days 
before the baseline visit) 
and at follow-up visits 
performed 1 week, 1 and 
2 months post-ablation. 
8.2.6 PREGNANCY TEST 
All female patients (regardless of childbearing potential) must undergo a serum pregnancy test 
at screening to confirm eligibility in the trial. 
In case an additional pregnancy test is indicated during the trial, a serum test should be 
performed. In case of pregnancy, the patient must be immediately withdrawn from the trial, and 
the pregnancy must be reported immediately following the same procedure as for SAE. 
Pregnancy, suspected pregnancy, or a positive pregnancy test should be reported within 24 
hours to the CRO Dynamic Science S.L. using the Pregnancy Report Form and following the 
same criteria than those established for SAE reporting (Section 9.4.1). 
8.3 OTHER ASSESSMENTS 
8.3.1 SCREENING PURPOSE 
8.3.1.1 AMERICAN SOCIETY OF ANESTHESIOLOGIST SCORE 
Anesthetic risk will be assessed at screening using the American Society of Anesthesiologist 
(ASA) score (55) (Appendix 7). It also referred to as ASA physical status (ASA-PS). The ASA 
physical status class risk stratification system is based on comorbid conditions that are a threat 
to life or that limit activity and thus helps in predicting preoperative risks.  
The ASA score will be used a global score to subjectively assess the physical status of patients 
before the procedure and estimate pre-operative risk. All patients must be assessed for their 
ASA-PS at screening to confirm eligibility in the study and before each ablation procedure 
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8.3.1.2 ELECTROCARDIOGRAM 
A standard 12 lead ECG will be performed at screening. In addition, an ECG will be performed 
as a part of the procedures performed before any ablation in case a period of more than 6 
months has elapsed since the last ECG.   
Interpretation of the tracing must be documented in the eCRF. Each ECG tracing should be 
labeled with the study code, patient number, date, and kept in the source documents at the 
study site.  
Clinically significant abnormalities present after the patient signed informed consent should be 
reported in the eCRF as medical history. Clinically significant findings must be discussed with 
the Sponsor prior to enrolling the patient in the study. New or worsened clinically significant 
findings occurring after informed consent must be recorded as AEs in the eCRF. 
8.3.2 PATIENT REPORTED OUTCOME ASSESSMENT  
8.3.2.1 PAIN ASSESSMENT 
The potential occurrence of pain post-ablation will be assessed using a 0 to 100 mm VAS, 
where 0 is “no pain” and 100 is “the maximum pain possible” (Appendix 5). Patients will be 
asked to mark the level of their pain on the 100 mm VAS at the day of the ablation (before the 
procedure), and within the 24 hours period post-ablation and one week after the procedure. The 
requirement of analgesic treatment will be also recorded at the same time when the pain 
assessment (VAS) is conducted. The use of analgesic will be recorded in the eCRF.  
8.3.2.2 QUALITY OF LIFE ASSESSMENT 
The quality of life of patients (QoL) will be evaluated using the validated Spanish version of the 
EORT QLQ-C30 questionnaire version 3.0 (56) (Appendix 4).   
The patients will be asked to complete the first pre-procedure questionnaire at the clinic and 
then to complete the questionnaire for the second time while they attend to the clinic 1 and 2 
months following the procedure. The questionnaire will be delivered to patients by site staff for 
self-completion at the clinic. The patients will be given brief instructions on how the 
questionnaire should be completed.  
The EORTC QLQ-C30 is a 30-item generic health-related QoL instrument designed to assess 
cancer patients’ physical, psychological and social functioning. It is composed of 9 multi-item 
scales (5 functional scales [physical, role, cognitive, emotional, and social], a global QoL scale 
[GQoL], and 3 symptom scales [fatigue, pain, and nausea and vomiting]), 5 single-item 
symptom scales assessing additional symptoms commonly reported by cancer patients 
(dyspnoea, loss of appetite, insomnia, constipation and diarrhea), and an item on the perceived 
financial impact of the disease.  
All of the scales and single-item measures range in score from 0–100. A high scale score 
represents a higher response level. Thus, a high score for a functional scale represents a 
high/healthy level of functioning. A high score for the global health status/QoL represents a high 
QoL. However, a high score for a symptom scale/item represents a high level of 
symptomatology/problems. 

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9 
SAFETY MONITORING AND REPORTING 
9.1 EXPECTED ADVERSE EVENTS  
The expected adverse events associated with the device when used clinically for liver tumor 
ablation include potential risks typically associated with other established ablation methods, 
ultrasound-energy-delivery related risks, patient positioning-related complications and potential 
cytotoxicity associated to the skin contact with the device transducer. In addition, patients will be 
under general anesthesia during the procedures, as respiration and motion needs to be 
controlled. The potential occurrence of anesthesia-related AEs must therefore be considered.  
Taking into consideration risks associated with other established ablation methods, ultrasound-
energy delivery, patient positioning, anesthesia, and preclinical experience with the device, the 
following potential clinical risks have been identified for non-invasive VORTX Rx® system and 
related procedure: 
Intervening tissue thermal injury, skin burn/irritation, rib burn, ,major blood vessel stenosis, 
major bile duct stenosis, lung damage, intestinal perforation, gallbladder damage/perforation, 
intervening tissue mechanical damage, petechial hemorrhage, intra-hepatic hematoma, 
hemothorax, 
intractable 
pleural 
effusion, 
tumor 
implantation, 
large 
blood 
vessel 
rupture/excessive bleeding, major bile duct rupture/biloma, excessive hemolysis, transient liver 
dysfunction/hepatic failure, ascites, chronic liver dysfunction/hepatic failure, liver abscess, 
peritoneal bleeding, diaphragmatic injury, unnecessary exposure to anesthesia, portal vein 
thrombosis, venous thrombosis, pulmonary embolism, cardiac arrest, post-ablation syndrome 
(delayed pain, nausea, fever, vomiting), pain, and death.  
9.2 SAFETY PLAN 
The VORTX Rx® was developed using HistoSonics’  International Organization for 
Standardization (ISO) 13485 - Quality Management System (QMS) procedures and to United 
States 21 Code of Federal Regulations (CFR) Part 820 Quality System Regulation,  ISO 14971 
Medical Devices – Application of Risk Management to Medical Devices and European (EU) 
Council Directive 93/42/EEC 2007 and the essential requirements for investigational devices in 
Annex X and MEDDEV 2.7/3 rev. 3 Clinical Investigations: Serious Adverse Event Reporting. 
The risk management plan is fully integrated with HistoSonics’ product realization procedures 
and design controls with the intent of eliminating, or minimizing, real and potential risks 
associated with the device to acceptable levels when compared with the potential benefits for 
the indicated use/intended purpose. The product risk analysis includes three types of 
development related analyses: 1) use hazard analysis (includes usability/human factors), 2) 
product design risk analysis, and 3) process risk analysis (manufacture and assembly to include 
safety testing), as well as a clinical risk analysis.  The entire process results in a risk 
management report that summarizes the risk mitigation efforts, details the residual risks, and 
documents risk management acceptance. 
The VORTX Rx® is a currently a production-equivalent device intended for investigational use 
only. The risk management plan is based on the clinical experience available with the device 
used in the feasibility study for BPH treatment, the proposed indications for use for liver, and the 
available preclinical experience in animal models and ongoing studies for soft tissue ablation. 
Please refer to the IB for a complete summary of safety information.  
Several measures will be taken to ensure the safety of patients participating in this study. 
Careful selection of patients to exclude patients at higher risk for toxicities, a detailed pre-
procedure patients’ assessment, participation by only qualified investigators, and close 
monitoring during the procedure and post-ablation follow-up are measures that will be employed 

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to minimize potential risks. Patients will undergo careful safety monitoring throughout the study, 
including assessments of the nature, frequency and severity of AEs.  
Clinical risks must be minimized by detailed assessment of the subject, especially in regard to 
coagulopathy, underlying hepatic reserve, and tumor proximity to major structures such as the 
bile duct or intestine, prior to, during and after the procedure by qualified investigators. In 
addition, close post-ablation follow-up of patients may minimize risks associated with the 
medical device and the procedure that may not have been anticipated and will allow for rapid 
response to any conditions that are presented.  
An independent DSMB will be used for review of safety data to provide advice to the sponsor 
regarding actions the board recommends to ensure the safety, protection and well-being of the 
subjects enrolled in the study. The members of the DSMB will be experts who are independent 
from the Sponsor.  Additional details regarding the structure of the DSMB is provided in Section 
9.5. 
9.3 ADVERSE EVENTS 
9.3.1 DEFINITIONS 
9.3.1.1 ADVERSE EVENT (AE) 
An AE is defined as any untoward medical occurrence, unintended disease or injury or any 
untoward clinical sign(s), symptom(s), or medical condition(s) (including abnormal laboratory 
finding if considered clinically significant by the investigator), in patients participating in a clinical 
investigation with a medical device, whether or not related to the investigational medical device.  
Pre-existing conditions will not be reported during the study unless exacerbated. Conditions that 
were already present at the time of informed consent will be recorded as medical history in the 
eCRF. Worsening of any pre-existing condition will be reported an AE, or as a SAE if the event 
meets the criteria for a SAE (see Section 9.3.1.2).  
Laboratory abnormalities and abnormal vital signs that are definitely or probably device related 
will be considered an AE if they are clinically significant in the investigator´s judgment, induce 
clinical signs or symptoms, or require a medical intervention or change in concomitant therapy. 
Medical and scientific judgment will be exercised in deciding whether an isolate laboratory or 
vital sign abnormality should be classified as an AE.  
The investigator will provide the study monitor with the normal laboratory values before the 
study initiation.  
AEs (including laboratory abnormalities that constitute an AE) will be described using a 
diagnosis whenever possible, rather than individual underlying signs and symptoms (e.g. 
anemia instead of low hemoglobin). When a clear diagnosis cannot be identified, each sign or 
symptom will be reported as a separate AE. 
The presence of post-procedure pain will not be recorded as an AE during the immediate follow-
up visits 1 day and 1 week after the procedure, as post-procedure pain will be expected data 
collected at these visits. However, pain will be recorded as an AE thereafter.  
The presence of complications from the point of ablation initiation will be recorded as AEs in the 
CRF, and it will be reported as a SAE if the event meets the seriousness criteria specified 
below.  

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9.3.1.2 SERIOUS ADVERSE EVENTS   
A serious adverse event is defined as any AE that meets at least one of the following criteria: 
 
It is fatal (death is a result, it is not an event) 
 
It is life-threatening (It refers to an AE 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 had been more serious).  
 
Requires inpatient hospitalization or prolongation of existing hospitalization (unplanned 
hospitalization during at least one night) 
 
Results in persistent or significant disability/incapacity. 
 
Constitutes a congenital anomaly/birth defect. 
 
Is medically significant, i.e., defined as an event that jeopardizes the patient or may 
require medical or surgical intervention to prevent one of the outcomes listed above. 
 
Note that planned hospitalization for pre-existing condition, or a procedure required by 
the Clinical Investigation Plan, without serious deterioration in health is not considered a 
SAE.  
9.3.1.3 ADVERSE DEVICE EFFECT (ADE)  
An adverse device effect (ADE) includes any AE resulting from insufficiencies or inadequacies 
in the instructions for use, the deployment, the implantation, the installation, the operation, or 
any malfunction of the investigational medical device. This includes any event that is a result of 
a use error or intentional misuse. 
9.3.1.4 UNANTICIPATED SERIOUS ADVERSE DEVICE EFFECTS (UADE) 
Any serious adverse effect on health or safety or any life-threatening problem or death caused 
by, or associated with, a device, if that effect, problem, or death was not previously identified in 
nature, severity, or degree of incidence in the investigational plan or application, or any other 
unanticipated serious problem associated with a device that relates to the rights, safety, or 
welfare of subjects.  
9.3.1.5 SERIOUS ADVERSE DEVICE EFFECT (SADE) 
Adverse device effect that has resulted in any of the consequences characteristic of a SAE. 
 
9.3.1.6  UNANTICIPATED SERIOUS ADVERSE DEVICE EFFECTS (USADE) 
Serious adverse device effect which by its nature, incidence, severity or outcome has not been 
identified in the current version of the risk analysis report. 
NOTE: Anticipated SADE (ASADE): an effect which by its nature, incidence, severity or 
outcome has been previously identified in the risk analysis report.  
9.3.2 CAUSALITY 
The relationship between the use of the medical device and the occurrence of each AE shall be 
assessed and categorized. During causality assessment activity, clinical judgement shall be 
used and the relevant documents, such as the IB and the Clinical Investigational Plan (CIP) 
shall 
be 
consulted. 
The 
presence 
of 
confounding 
factors, 
such 
as 
concomitant 

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medication/treatment, the natural history of the underlying disease, other concurrent illness or 
risk factors shall also be considered.  
The investigator will assess the reasonable possibility that the study medical device either 
caused or contributed to the AE.  
The Sponsor and the investigators will use the following definitions to assess the relationship of 
the AE to the investigational medical device:  
 
Not related: relationship to the device or procedures can be excluded when: 
o 
the event is not a known side effect of the product category the device belongs 
to or of similar devices; 
o 
the event has no temporal relationship with the use of the investigational device 
or the procedures;  
o 
the discontinuation of the medical device application does not impact on the 
event: 
o 
the event involves a body-site or an organ not expected to be affected by the 
device. 
o 
the serious event can be attributed to another cause (e.g. an underlying or 
concurrent illness/ clinical condition, an effect of another device, drug, treatment 
or other risk factors); 
o 
harms to the subject are not clearly due to use error; 
o 
In order to establish the non-relatedness, not all the criteria listed above might 
be met at the same time, depending on the type of device/procedures and the 
event.  
 
Unlikely: the relationship with the use of the device seems not relevant and/or the event 
can be reasonably explained by another cause, but additional information may be 
obtained. 
 
Possible: the relationship with the use of the investigational device is weak but cannot 
be ruled out completely. Alternative causes are also possible (e.g. an underlying or 
concurrent illness/ clinical condition or/and an effect of another device, drug or 
treatment). Cases were relatedness cannot be assessed or no information has been 
obtained should also be classified as possible. 
 
Probable: the relationship with the use of the investigational device seems relevant 
and/or the event cannot reasonably be explained by another cause, but additional 
information may be obtained.  
 
Causal relationship: the adverse event is associated with the investigational device or 
with procedures beyond reasonable doubt when: 
o 
the event is a known side effect of the product category the device belongs to or 
of similar devices and procedures;  
o 
the event has a temporal relationship with investigational device use/application 
or procedures;  
o 
the event involves a body-site or organ that  
 
the investigational device is applied to 
 
the investigational device has an effect on; 
o 
the event follows a known response pattern to the medical device (if the 
response pattern is previously known); 
o 
other possible causes (e.g. an underlying or concurrent illness/ clinical condition 
or/and an effect of another device, drug or treatment) have been adequately 
ruled out; 
o 
harm to the subject is due to error in use; 

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o 
To establish the relatedness, not all the criteria listed above might be met at the 
same time, depending on the type of device and the serious event. 
The Sponsor and the investigators will distinguish between the AEs related to the investigational 
device and those related to the procedures (any procedure specific to the clinical investigation). 
An AE can be related both to procedures and the investigational device. Complications of 
procedures are considered not related if the said procedures would have been applied to the 
patients also in the absence of investigational device use/application. 
In some cases, the event may be not adequately assessed because information is insufficient or 
contradictory and/or the data cannot be verified or supplemented. The Sponsor and the 
Investigators will make the maximum effort to define and categorize the event and avoid these 
situations. Where the Sponsor remains uncertain about classifying the serious event, it should 
not exclude the relatedness and classify the event as “possible”. 
 
9.3.3 SEVERITY 
The severity of the AEs will be assessed according to the NCI CTCAE version 4.0 (44) 
(Appendix 2). If NCI CTCAE grading does not exist for an AE, the severity of mild, moderate, 
severe, life-threatening and death, corresponding to grades 1 - 5, will be used:  
 
Grade 
Severity 
1 
Mild; asymptomatic or mild symptoms; clinical or diagnostic observations 
only; intervention not indicated. 
2 
Moderate; minimal, local or noninvasive intervention indicated; limiting age-
appropriate instrumental activities of daily living (ADL)a. 
3 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting 
self care ADLb,c 
4 
Life-threatening consequences; urgent intervention indicated d.  
5 
Death related to AE d.   
 
Instrumental ADL refer to preparing meals, shopping for groceries or clothes, using the telephone, 
managing money, etc.  
 
Self care ADL refer to bathing, dressing and undressing, feeding self, using the toilet, taking 
medications, and not bedridden. 
 
If an event is assessed as “medically significant” it must be reported as a SAE.  
 
Grade 5 AE must be reported as a SAE. 
9.4 COLLECTING AND REPORTING OF ADVERSE EVENTS 
The investigator must record all AEs, whether or not related to the use of the study medical 
device in the CRF.  
The occurrence of AEs should be sought by questioning of the patient during the screening 
process after signing informed consent and at each visit during the study. AEs also may be 
detected when they are volunteered by the patient during the screening process or between 
visits, or through physical examination, laboratory test, or other assessments.  
As far as possible, the following information will be collected for each AE in the CRF: 

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 
The severity grade according to the NCI CTCAE version 4.0 (Appendix 2). 
 
Its duration (start and end dates, or ongoing at end of study). 
 
Its suspected relationship to the investigational device (VORTX Rx®) 
 
Whether any medication or therapy was given due to the AE. If a concomitant 
medication or non-drug therapy is given, this action should be recorded on the eCRF. 
 
Whether it is serious.  
 
Its outcome. 
Once an AE is detected, it should be followed until its resolution or until it is judged to be 
stabilized; an assessment should be made at each visit (or more frequently, if necessary) of any 
changes in severity, the suspected relationship to the medical device, the interventions required 
to treat it, and the outcome. 
9.4.1 REPORTING OF SERIOUS ADVERSE EVENTS 
9.4.1.1 REPORT BY THE INVESTIGATOR TO THE SPONSOR 
Every SAE, regardless of suspected causality, occurring after ablation initiation, will be reported 
to the Sponsor within 24 hours of learning of its occurrence. The new findings/updates to the 
already reported SAE will be notified as follow-up to the original episode within 24 hours of the 
investigator after awareness by the investigator.  
Information about all SAEs will be collected and recorded on the SAE Form where all applicable 
sections of the form must be completed. The investigator will assess and record the relationship 
of each SAE to the study medical device or the procedure, complete the SAE Form in English, 
and send the completed, signed form by fax within 24 hours to the CRO Dynamic Science S.L. 
(Fax: +34 914561126), who will communicate the SAEs to the Sponsor. The original copy of the 
SAE Form and the fax confirmation sheet will be kept with the eCRF documentation at the study 
site. 
9.4.1.2 REPORT BY THE SPONSOR TO THE COMPETENT AUTHORITIES 
SAE reporting to the National Competent Authorities will be conducted according to the 
MEDDEV 2.7/3 revision 3 (May 2015) guideline for SAEs reporting in clinical investigations with 
medical devices in line with the requirements of Annex 7 of Directive 90/385/EEC and Annex X 
of Directive 93/42/EEC, as amended by Directive 2007/47/EC, and the Circular 07/2004 
regulating clinical investigations with medical devices. The sponsor will report all SAEs to 
Spanish Agency of Medicines and Medical Devices (Agencia Española de Medicamentos y 
Productos Sanitarios - AEMPS acronym in Spanish) and to the applicable CEIm.   
The Sponsor will notify the AEMPS of all SAEs experienced since commencement of the 
procedure, regardless of suspected causal relationship no later than 7 days after occurrence. 
For SAEs which indicate an imminent risk of death, serious injury, or serious illness, that 
requires prompt remedial action for other patients/subjects, users or other persons* or a new 
finding to it, the SAE reporting to the AEMPS will be performed immediately, but not later than 2 
calendar days after awareness by sponsor of a new reportable event or of new information in 
relation with an already reported event.  
The completed SAE report form will be sent by email in Excel to the AEMPS, or an equivalent 
format which allows using the inserted filters. 
The SAE reporting will be updated and transmitted to the AEMPS each time a new reportable 
event or a new finding/update to an already reported event is to be reported. More detailed 
information will be provided on request of the AEMPS, if so requested by using the individual 

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reporting form. The Sponsor shall identify the new/updated information in the status column of 
the tabular form as: 
a = added = new reportable event; 
m = modified =new finding/update to an already reported event; 
u = unchanged 
Changes in a line should be highlighted in bold and/or color in the respective column. 
* This includes: A) events that are of significant and unexpected nature such that they become alarming as a potential 
public health hazard, e.g. human immunodeficiency virus (HIV) or Creutzfeldt-Jacob Disease (CJD). These concerns 
may be identified by either the NCA or the manufacturer. B) the possibility of multiple deaths occurring at short intervals.  
 
9.5  DATA AND SAFETY MONITORING BOARD 
The Data and Safety Monitoring Board (DSMB) is an independent group of experts that advises 
study team, sponsor and the study investigators. The members of the DSMB serve in an 
individual capacity and provide their expertise and recommendations. The members of the 
DSMB will be experts who are independent from the Sponsor.   
This board will convene at regular intervals to review any SAEs and device malfunctions that 
occur during the study.  The DSMB will serve as a data monitor and make recommendations 
based on the data regarding the safety of patients utilizing a risk/benefit ratio in relation to the 
study and ablation outcomes. The DSMB will make recommendations to the study sponsor 
regarding the safety of the study, and whether the study should continue under the current 
protocol, under a revised protocol or be stopped due to safety concerns. The DSMB may also 
recommend halting enrollment to perform a detailed review of a device or patient situation/AE 
that is unexpected or in a higher frequency than has previously been reported.  Patient safety is 
the highest priority for this study, involving this device and procedure.  A DSMB charter will be 
developed, which will outline the guidelines the DSMB will use to review and make 
recommendations to the Sponsor regarding study continuation.  
DSMB Composition: The composition DSMB for this study will be included in the DSMB 
Charter.   
DSMB meetings/review frequency: It is anticipated the DSMB will meet monthly for this study; 
however, meetings may be postponed or cancelled due to lack of new data.  
The DSMB will review the research protocol and plans for data and safety monitoring.  Once 
monthly, the DSMB will review the study’s data manager’s report that will include the following 
information:  
 
The number of participants consented for the study  
 
The reasons for withdrawal (if any) from the study 
 
Any safety concerns revealed during the course of the study 
 
Summary of AEs and serious AEs  
 
Summary of UADEs  
 
The current, approved consent form  
Any material presented to the DSMB will be presented in a way to preserve patient 
confidentiality.  The DSMB will also review the investigator’s summary of any new data or 
evidence that might alter the risk/benefit ratio for participating in the study.  After reviewing this 
information, the DSMB will hold a meeting with the Study Sponsor and report its summary of 
any serious and unexpected AEs, UADEs, or other unanticipated problems that involve risk to 

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study participants, and whether these appear related to the study-based interventions.  Minutes 
of such meeting will be prepared to document the DSMB’s communication to the study sponsor.  
The membership of the DSMB should reflect the disciplines and medical specialties necessary 
to interpret the data from the clinical study and to fully evaluate participant safety. The number 
of DSMB members, will be based on the complexity in design and analysis, and potential level 
of risk but generally consists of three to seven members with desired participation from:  
 
Expert(s) in the clinical aspects of the disease/patient population being studied;  
 
A biostatistician; and,  
 
Investigators with expertise in current clinical study conduct and methodology 
Ad hoc specialists may be invited to participate as non-voting members at any time if additional 
expertise is desired.  
Staff without direct involvement in study implementation and who meet other membership criteria may 
participate as ex officio, non-voting members.  Staff serving in these positions must have a current 
confidential financial disclosure report on file.  Representatives of the sponsor (industry) of the 
test device or any other individual with vested interests in the outcome of the study are not 
eligible to serve on the DSMB although they may attend open sessions of the DSMB meetings. 
No member of the DSMB should have direct involvement in the conduct of the study. 
There will be regular, ongoing communication between the study sponsor, the investigator and 
the DSMB. The investigator will take responsibility for reporting any serious and unexpected 
AEs or other unanticipated study problems to the study sponsor, and, where required, the 
Competent Authority.  A copy of each report will be sent to the DSMB. Actions taken by the 
ethics committee in response to AE reports will be immediately reported to the DSMB, 
investigators and study sponsor, which will review all SAEs, as they arise. 
10 STATISTICAL METHODS AND DATA ANALYSIS 
10.1 SAMPLE CALCULATION 
No formal statistical power calculations to determine sample size is performed for this study due 
to the nature of this study design and patient population.  
Due to the nature of this study in which the investigational device will be used for the first time 
for soft tissue ablation of liver tumors in humans, the approximate number of patients planned to 
be included in this study is 10.   
10.2 OVERALL CONSIDERATIONS 
Upon completion of the study, after the data for the final study patient have been recorded, and 
once all possible data discrepancies have been resolved, the study database will be locked and 
transferred to the person responsible for statistical analysis. 
A detailed statistical analysis plan will be prepared at the appropriate time, which will be 
approved by the sponsor, to guide the analysis of the data and justify any change in the original 
plan. 
A general description will be given of the variables included in the study and non-parametric 
tests will be performed if applicable.  
There are no plans to allocate unavailable data, which will simply be described as missing data.  
The statistical analysis of the study data will be carried by the biometrics department of Dynamic 
Science S.L.  

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No interim analyses are planned. 
10.3 ANALYSIS SETS 
10.3.1 
FULL ANALYSIS SET 
The full analysis set includes all patients who have undergone an ablation with the 
investigational device. The full analysis set will be used for all listings of raw data.  
10.3.2 
SAFETY POPULATION 
The study population that will be included in the safety analysis consist of all patients who have 
undergone an ablation with the investigational device.  
10.3.3 
TECHNICAL PERFORMANCE POPULATION 
The technical performance population set includes all patients who have undergone an ablation 
with the investigational device and have an assessment of technical performance.  
10.4 PATIENT DEMOGRAPHICS/OTHER BASELINE CHARACTERISTICS 
Demographic and other baseline data will be summarized descriptively for the full analysis set.  
10.5 PRIMARY OBJECTIVE/ENDPOINT 
The primary objective of the study is to evaluate the acute technical performance of the VORTX 
Rx® medical device for the ablation of primary and metastatic liver tumors. The ability of the 
investigational device to create an ablation zone that correspond to the PAV (a three-
dimensional volume defined by the investigator using the VORTX Rx® in the planning phase of 
the software workflow) will be assessed by multi-dimensional measurement of the 1 day post-
procedure ablation zone and accompanied by general radiological findings characterized 
(qualitatively) in radiology report from a central radiologist reader applying The International 
Working Group Image-guided Tumor Ablation guidance (42, 45). The acute technical success of 
up to 3 separate tumor ablations will be assessed in each patient.   
The number of targeted tumors in whom technical success is achieved (ablation zone 
corresponds to PAV) will be divided by the number of targeted tumors in which the ablation has 
been initiated with the investigational device to calculate technical success percentage.  
 
10.6 SECONDARY OBJECTIVES 
 
Safety profile of the investigational medical device will be assessed on the basis of all AEs 
(serious and non-serious, and probably or definitively related to the medical device) 
experienced during the procedure conducted with this medical device and all observed and 
volunteered AEs and abnormal findings on physical examination, vital signs, laboratory and 
imaging tests throughout the study. 
The safety analysis will be performed in the “safety population” which includes all patients 
who have undergone an ablation with the VORTX Rx® medical device.  
All AEs recorded during the study will be listed and summarized. All SAEs will be listed by 
patients. Any other safety information will be listed and tabulated as appropriate. This 

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includes analysis of all AE and SAEs throughout the study, physical examinations, changes 
in vital signs, ECOG performance status, laboratory values, and ECG. 
Summary tables for AEs should include only AEs that started or worsened during the 
ablation and post-ablation follow-up period (2 months).  
The incidence of ablation-emergent AEs (new or worsening since ablation initiation) will be 
summarized by system organ class and or preferred term, severity (based on CTCAE 
version 4.0 grades), type of AE, whether they were SAEs or not, and relation to the medical 
device under study.  
The incidence of the following AEs, if definitively related to the study medical device, will be 
evaluated:  
1. Major bleeding that requires transfusion within 48 hours 
2. Visceral perforation (bowel or stomach)  
3. Major biliary duct injury 
4. Death 
The safety profile of the study will be deemed favorable if there are:  
 
No deaths due to the ablation, and 
 
No deaths from visceral perforation (bowel or stomach), and 
 
20% or lower incidence of major bleeding requiring transfusion within 48h, and  
 
20% or lower incidence major bile duct injury. 
 
To assess the local tumor progression. 
o 
Assessment of the ablation zone of each tumor will be conducted by a central-
reader radiologist based on local tumor progression according to the International 
Working Group Image-guided Tumor Ablation (42, 45) (Appendix 3) at 1-week, 1 
month and 2 months post-ablation.   
 
To assess the involution of the ablation zone.  
o 
The size of each tumor ablation zone on MRI and optional CT will be captured at 
each post-ablation follow up visit will be assessed and compared at 1-week, 1 
month and 2 months post-ablation.  
 
To assess liver panel post-ablation.  
o 
The change in the levels of the liver function parameters (AST, ALT, alkaline 
phosphatase, albumin, bilirubin, GGT, PT and INR) will be calculated from baseline 
to the post-procedure evaluation performed 24 hours post-ablation and the follow-
up visits performed 1 week, and 1 and 2 months post-procedure.  
 
To evaluate immunological response of ablation  
o 
The change in the levels from immune tests (Immune tests including: CD3+, CD4+, 
CD8+, CD45+, CD16+, CD56+ and CD19+, CRP, complement C3, C4 and CH50, 
immunoglobulins (IgG, IgM, IgA)), IL-6, and tumor biomarkers (CEA, AFP, Cancer 
Antigens CA15-3 (Breast Cancer) and CA 19-9 (Pancreatic Cancer) (50, 51) will be 
calculated from baseline to the post-procedure evaluation performed 24 hours post-
procedure and the follow-up visits performed 1 week, and 1 and 2 months post-
procedure. 
 
To evaluate patient quality of life of patient’s post-procedure.   
o 
For the analysis of change of quality of life, the descriptive statistics of the score of 
the dimensions and the total score of the QLQ-C30 questionnaire will be performed, 
and the change from the screening to the visits at 1 and 2 months post-procedure 
will be calculated.  

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o 
QLQ-C30 scores will be generated according to the EORTC Scoring Manual 
(Appendix 4). These scores vary from 0 (worst) to 100 (best) for the GHS and 
functional scales, and from 0 (best) to 100 (worst) for symptomatic scales.  
 
To assess pain and analgesic requirements post-procedure.  
o 
The VAS scale score will be calculated 24 hours and 1 week post-procedure and 
the change in pain score will be analyzed (Appendix 5).  
o 
The number of patients requiring analgesics 24 hours and 1 week post-procedure 
will be calculated and compared.  
11 ETHICAL CONSIDERATIONS 
11.1 REGULATORY AND ETHICAL COMPLIANCE 
This clinical trial will be conducted in accordance with the protocol, the principles established in 
the current revised version of the Declaration of Helsinki (Fortaleza, Brazil; October 2013), and 
in accordance with applicable regulatory requirements for investigations with medical devices, in 
particular the Circular 7/2004 of the AEMPS regulating the clinical investigations with medical 
devices. 
By signing the protocol, the investigator agrees to adhere to the instructions and procedures 
described in the protocol and thereby to adhere to the principles of good clinical practice for 
medical device trials that it conforms to. 
The sponsor will submit the pertinent documentation to the CEIm. The study may not be started 
until approval by the CEIm and the AEMPS has been obtained. 
Handling, communication and transfer of the personal data for all the participating subjects will 
comply with the stipulations of the Regulation (EU) 2016/679 on Personal Data Protection. The 
investigator and study data will be entered and processed in a file owned by the sponsor, which 
will be held by Dynamic Science, in accordance with the aforementioned Organic Law.  
The study staff involved in the conduct of this trial will be appropriately qualified education, 
training and experience to perform the assigned tasks. 
11.2 INFORMED CONSENT PROCEDURES 
Each subject who is asked to participate in the study will be informed about the same both orally 
and in writing providing them with a document called “Patient Information Sheet”, which will 
contain the necessary relevant information for the patient in a form that is entirely legible and 
comprehensible to decide if he/she wishes to participate in the trial (Appendix 1). 
It is the responsibility of the investigator to obtain informed consent from each patient 
participating in the study after explaining the objectives, methods, potential benefits and risks of 
the study deriving from their participation in the study, the confidentiality of personal data and 
the contact details for the doctor responsible for the study. Consent must be obtained before 
performing any study-specific procedure. Each patient should be explained in a clear and 
unequivocal manner that he/she is free to refuse to participate in the study and that he/she may 
withdraw his/her consent at any time for any reason without penalty or refusal of the best 
treatment as the investigator’s discretion. The investigators must keep the signed informed 
consent in the study file and it must be documented in the eCRF and in the patients’ medical 
records. The investigator will obtain the subject’s informed consent (preferably in writing, or if 
not feasible, orally before witnesses independent of the research team). In addition, the subject 
participating in the study must be given a copy of the informed consent. 

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11.3 CONFIDENTIALITY 
The information disclosed and obtained during this study will be considered confidential and 
must be treated as such at all times. 
The study data and materials may not be disclosed in part or in full by the investigator or his/her 
staff to any unauthorized person without the prior formal written consent of the sponsor. 
All materials, information (oral or written) and unpublished documentation provided to the 
investigators, including this protocol and the CRFs (electronic and/or paper), and all documents 
generated during the study and the database, will be considered the property of the sponsor, 
and will be protected from non-permitted uses by persons unrelated to the research and, 
therefore, will be considered strictly confidential and will not be disclosed to third parties except 
for those specified in the subsequent paragraph. 
The investigator and the institution will permit direct access to the source data and documents 
for the performance of monitoring, auditing, review by the medicinal product research ethics 
committee, and trial inspection by the health authorities. This access will be restricted to the 
sponsor, monitor, study doctors and their research staff, the AEMPS, the competent health 
authorities of the autonomous communities, the CEIm, and the sponsor or personnel authorized 
by the sponsor, when necessary to verify the study data and procedures, but always 
maintaining their confidentiality in accordance to current legislation. 
Only medical history data that are related to the study will be subject to verification. This 
verification will be done to the extent possible in the presence of the principal 
investigator/coinvestigators, and the confidentiality of all personal data of the subjects 
participating in the clinical trial will be maintained at all times in accordance with the Regulation 
(EU) 2016/679 on Personal Data Protection. 
Handling, communication and transfer of the personal data for all the participating subjects will 
comply with the stipulations of the Regulation (EU) 2016/679 on Personal Data Protection. The 
investigator and study data will be entered and processed in a file owned by the sponsor, which 
will be held by Dynamic Science, in accordance with the aforementioned Organic Law.  
12 PRACTICAL CONSIDERATIONS 
12.1 ARCHIVING  
For the purpose of the clinical trial, a file will be generated with all the study documentation, 
including the protocol, CRF, signed informed consents, reports of SAEs and authorizations of 
National Competent Authorities. One copy of which will be kept by the investigator at his/her site 
(investigator file) and another by the sponsor (sponsor file). The content of these files will 
comply with the requirements for study documentation in applicable legislation. 
The study documentation will be kept for the time required by currently applicable legislation. 
12.2 SOURCE DOCUMENTS 
The CRF will be considered the source document for the VAS scale for pain assessment and 
the quality of life questionnaire QLQ-C30, since these specific study procedures are not 
performed under clinical practice conditions.   
 

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Access to source documents 
The study will be monitored by regular visits and phone calls to the investigator. During visits to 
the study site, the monitor must review the original patient records, medication records and 
document storage. The monitor must also evaluate the study procedures and discuss any 
possible problems with the investigator. During the course of the study, auditing visits to the 
participating sites may be performed. 
In compliance with applicable regulations, the investigator and his/her team as well as the study 
site are required to permit authorized representatives of the study sponsor, regulatory agencies 
and the CEIm direct access for review of the data/documents of the patients’ original medical 
records for verification of the study procedures and study-related data. This direct access 
includes examination, analysis, verification and reproduction of any record or report that is 
important for evaluation of the study. The investigator is obliged to inform and obtain consent 
from the subject to permit access by designated representative to the subject’s study-related 
records without violating the confidentiality of the subject. 
13 QUALITY CONTROL 
13.1 STUDY MONITORING 
The accuracy of the data recorded in the eCRF will be verified by study monitor by verifying the 
recorded data. During the study, monitoring visits will be performed to ensure the study 
complies with all aspects of the protocol, good clinical practice (GCP) guidelines and applicable 
legislation. The source documents (original documents, data and records) will be reviewed to 
verify the information recorded in the eCRFs. The investigator and the site will ensure the 
sponsor or its representative (including the monitor), the CEIm and the health authorities have 
access to the study documents. This access includes the investigator file, eCRF, patient 
information sheet and informed consent, medical histories of the subjects and other source 
documents. It is important that the investigator and study staff be available during the monitoring 
visits and devotes sufficient time to the process. 
14 FUNDING  
All financial aspects related to the clinical trial will be specified in a contract between the 
sponsor and the sites where the trial is to be conducted. The financial budget of the study will 
be made available to the CEim for its evaluation. 
The sponsor will fund the study in accordance with the guidelines of the present protocol. This 
funding includes all materials necessary to conduct the study; the cost of the authorization and 
control processes with the research and health authorities; design, maintenance and 
management of the database; and statistical analysis of the information generated. In any 
event, the funding shall be independent of the results of the study.  
As required by current legislation and in particular by the Circular 07/2004, the sponsor has 
taken out an insurance policy with the company Chubb European Group Limited, with an 
address at Paseo de la Castellana 141, 6 Planta 28046 Madrid, España and with policy number 
ESCAIA21218, which covers the liabilities of the sponsor/principal investigator, the research 
staff and the sites where the clinical trial is conducted, in the event of any damage or injury to 
the health of the patient resulting from this research, conducted strictly in accordance with both 
the scientific protocol and applicable law in Spain and professional standards, during the 
conduct of the study and for one year following termination of the study, unless otherwise 
proven. 

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15 PUBLICATION GUIDELINES 
All information related to the study is considered confidential and property of the sponsor until its 
publication. It must not be revealed to others without prior written consent from the sponsor. 
Once the study has been completed and the statistical report has been performed, the sponsor, 
in conjunction with the investigators, will prepare the final study report, which will be submitted 
to the investigators, the research ethics committees, the AEMPS and the health authorities, if so 
requested. This final report will be the basis for the preparation of the manuscripts that are 
desired to be published in medical journals. 
The sponsor is obliged to publish the results, whether positive or negative, in scientific journals, 
meetings and/or congresses, before being disclosed to the non-healthcare public, indicating the 
funding obtained for conduct of the trial and ensuring at all times the anonymity of the 
participating subjects. 
The results or conclusions of this study will be reported at scientific congresses and published in 
scientific journals. The investigator agrees to maintain this information in strict confidence, and 
will not use it for any other purpose without the written authorization of the sponsor. 

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17 APPENDICES 
 
 
APPENDIX 1. Patient information sheet and informed consent form (ICF) 
Attached as separate documents. 

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APPENDIX 2. NCI-CTCAE (Version 4.0) 
Attached as a separate document. 

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APPENDIX 3. International Working Group on Image-Guided Tumor 
Ablation Guidance Document 
Attached as a separate document. 

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APPENDIX 4. EORTC QLQ-C30 questionnaire 
Attached as a separate document. 

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APPENDIX 5. VAS for pain assessment  
Attached as a separate document. 

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APPENDIX 6. Eastern Cooperative Oncology Group performance status 
(ECOG) 
Grade 
Performance status 
0 
Fully active, able to carry on all pre-disease performance without restriction. 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a 
light or sedentary nature, e.g., light house work, office work. 
2 
Ambulatory and capable of all self care but unable to carry out any work activities. Up and 
about more than 50% of waking hours. 
3 
Capable of only limited self care, confined to bed or chair more than 50% of waking hours. 
4 
Completely disabled. Cannot carry on any self care. Totally confined to bed or chair. 
5 
Dead. 
Source: Oken et al (1982). 

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APPENDIX 7. American Society of Anesthesiologist score  
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM 
Last approved by the ASA House of Delegates on October 15, 2014 
Current definitions (NO CHANGE) and Examples (NEW) 
ASA PS 
Classification 
Definition 
Examples, including, but not 
limited to: 
ASA I 
A normal healthy patient 
Healthy, 
non-smoking, 
no 
or 
minimal alcohol use 
ASA II 
A patient with mild systemic disease 
Mild 
diseases 
only 
without 
substantive functional limitations. 
Examples include (but not limited 
to): current smoker, social alcohol 
drinker, pregnancy, obesity (30 < 
BMI 
< 
40), 
well-controlled 
DM/HTN, mild lung disease 
ASA III 
A patient with severe systemic disease 
Substantive functional limitations; 
One or more moderate to severe 
diseases. Examples include (but 
not limited to): poorly controlled 
DM 
or 
HTN, 
COPD, 
morbid 
obesity (BMI ≥40), active hepatitis, 
alcohol dependence or abuse, 
implanted pacemaker, moderate 
reduction 
of 
ejection 
fraction, 
ESRD 
undergoing 
regularly 
scheduled 
dialysis, 
premature 
infant PCA < 60 weeks, history 
(>3 months) of MI, CVA, TIA, or 
CAD/stents. 
ASA IV 
A patient with severe systemic disease 
that is a constant threat to life 
Examples include (but not limited 
to): recent (< 3 months) MI, CVA, 
TIA, 
or 
CAD/stents, 
ongoing 
cardiac ischemia or severe valve 
dysfunction, severe reduction of 
ejection fraction, sepsis, DIC, ARD 
or ESRD not undergoing regularly 
scheduled dialysis 
ASA V 
A moribund patient who is not expected 
to survive without the operation 
Examples include (but not limited 
to): ruptured abdominal/thoracic 
aneurysm, 
massive 
trauma, 
intracranial bleed with mass effect, 
ischemic bowel in the face of 
significant cardiac pathology or 
multiple organ/system dysfunction 
ASA VI 
A declared brain-dead patient whose 
organs are being removed for donor 
purposes 
 
*The addition of “E” denotes Emergency surgery: (An emergency is defined as existing when 
delay in treatment of the patient would lead to a significant increase in the threat to life or body 
part)