A Proof-of-principle Study of Hyperbaric Oxygen as a Radiosensitizer Prior to Stereotactic Radiosurgery for Brain Metastases
Phase: NA
Conditions: Brain Metastases
Sponsor: Dartmouth-Hitchcock Medical Center

CONFIDENTIAL
CLINICAL RESEARCH 
A proof-of-principle study of hyperbaric oxygen as a radiosensitizer prior to 
stereotactic radiosurgery for brain metastases
Principal Investigator:
Alan Hartford, M.D., Ph.D., FACR
Section of Radiation Oncology
Dartmouth-Hitchcock Medical Center
One Medical Center Drive
Lebanon, NH 03756
603-650-6600
Co-investigators
Jay Buckey, M.D. (hyperbaric medicine)
David Gladstone, Sc.D. (radiation physics)
Gregory Russo, M.D. (radiation oncology)
Clifford Eskey, M.D., Ph.D. (neuroradiology)
Arti Gaur, Ph.D. (neurobiology and translational science)
Ben Williams, Ph.D. (radiation physics and radiobiology)
Biostatistical Support
Tor Tosteson, Ph.D. (biostatistics)
Zhongze Li, M.S. (biostatistics)
Radiology
Clifford Eskey, M.D., Ph.D. (neuroradiology)
Pathology
Research staff
Divya Ravi, M.S.
Suzanne Vaughn, R.N., O.C.N.
Funding Sponsor:
NCCC-Clinical Translational Research Program
Dartmouth-Hitchcock Medical Center
Study Product:
Hyperbaric oxygen as radiosensitizer for SRS treatment
Protocol Number:
D12129
IND Number:
Not applicable
Initial Version:
[7 June 2012] V1
Amended:
[17 August 2012] V2
Amended:
[25 July 2013] V3
Amended: 
[28 February 2014] V4
Amended: 
[17 October 2014] V5
Amended: 
[07 November 2014] V6
Amended: 
[20 January 2015] V7
Amended:
[18 April 2018] V8
Amended:
[11 April 2019] V9
Amended:
    [17 March 2020] V10

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Table of Contents
STUDY SUMMARY..........................................................................................................1
1
INTRODUCTION.......................................................................................................2
1.1
BACKGROUND ......................................................................................................2
1.2
INVESTIGATIONAL AGENT.......................................................................................7
1.3
PRECLINICAL DATA ...............................................................................................7
1.4
CLINICAL DATA.....................................................................................................8
1.5
DOSE RATIONALE AND RISK/BENEFITS...................................................................9
2
STUDY DESIGN......................................................................................................10
2.1
GENERAL DESIGN...............................................................................................10
2.1.1 Study Objectives...........................................................................................10
2.1.2 Study Flowchart............................................................................................10
2.2
PRIMARY STUDY ENDPOINTS...............................................................................11
2.3
SECONDARY STUDY ENDPOINTS..........................................................................11
2.4
FURTHER EXPLORATORY STUDY ENDPOINTS........................................................12
3
SUBJECT SELECTION AND WITHDRAWAL .......................................................13
3.1
INCLUSION CRITERIA...........................................................................................13
3.2
EXCLUSION CRITERIA..........................................................................................14
3.3
SUBJECT RECRUITMENT AND SCREENING.............................................................15
3.4
EARLY WITHDRAWAL OF SUBJECTS......................................................................15
3.4.1 When and How to Withdraw Subjects ..........................................................15
3.4.2 Data Collection and Follow-up for Withdrawn Subjects................................15
3.4.3 Replacement of withdrawn subjects .............................................................16
4
STUDY INTERVENTION.........................................................................................16
4.1
DESCRIPTION .....................................................................................................16
4.2
TREATMENT REGIMEN.........................................................................................16
4.3
ACUTE HBO TOXICITY.........................................................................................16
4.4
PRIOR AND CONCOMITANT THERAPY....................................................................17
5
STUDY PROCEDURES (SEE ATTACHED TABLE, SECTION 14.1)....................17
5.1
VISIT 1 – “INITIAL CONSULTATION VISIT”................................................................17
5.2
VISIT 2 – “PRETREATMENT VISIT” .........................................................................18
5.3
VISIT 3 – “SRS TREATMENT VISIT” ......................................................................18
5.3.1 Principles: .....................................................................................................18
5.3.2 Equipment:....................................................................................................18
5.3.3 Protocol Volume Target Definitions: .............................................................19
5.3.4 Gross Tumor Volume (GTV):........................................................................19
5.3.5 Planning Target Volume (PTV):....................................................................19
5.3.6 Timing of Radiotherapy:................................................................................19
5.3.7 Target Dose:.................................................................................................19
5.3.8 Normal Tissue Tolerance:.............................................................................19
5.3.9 Optional Blood Draw for Markers..................................................................19
5.4
FOLLOW-UP VISITS..............................................................................................20

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6
STATISTICAL PLAN ..............................................................................................20
6.1
STATISTICAL METHODS .......................................................................................20
6.2
SAMPLE SIZE DETERMINATION.............................................................................22
6.3
SUBJECT POPULATION(S) FOR ANALYSIS..............................................................22
7
SAFETY AND ADVERSE EVENTS........................................................................22
7.1
DEFINITIONS.......................................................................................................22
7.2
RECORDING OF ADVERSE EVENTS.......................................................................25
7.3
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS .........25
7.3.1 Investigator reporting: notifying the IRB........................................................26
7.4
STOPPING RULES ...............................................................................................26
8
DATA HANDLING AND RECORD KEEPING........................................................27
8.1
CONFIDENTIALITY ...............................................................................................27
8.2
SOURCE DOCUMENTS.........................................................................................27
8.3
CASE REPORT FORMS ........................................................................................27
8.4
RECORDS RETENTION.........................................................................................28
9
STUDY MONITORING, AUDITING, AND INSPECTING........................................28
9.1
SAFETY AND DATA MONITORING ..........................................................................28
9.2
ON-SITE MONITORING ........................................................................................28
9.3
AUDITING AND INSPECTING..................................................................................28
10
ETHICAL CONSIDERATIONS ...............................................................................29
11
STUDY FINANCES.................................................................................................29
11.1
FUNDING SOURCE ..............................................................................................29
11.2
CONFLICT OF INTEREST.......................................................................................29
12
PUBLICATION PLAN .............................................................................................29
13
REFERENCES........................................................................................................29
14
ATTACHMENTS .....................................................................................................32
14.1
TABLE SUMMARIZING STUDY PROCEDURES/FLOWCHART ........................................32
14.2
SAE REPORTING FORM ......................................................................................33
14.3
HBO TREATMENT PROTOCOL (INCLUDING “DRY RUN”)...........................................33
14.4
QUALITY OF LIFE INSTRUMENTS...........................................................................34
14.4.1
St. Louis University Mental Status (SLUMS) exam...................................34
14.4.2
EORTC QLQ C-30 ....................................................................................35
14.4.3
EORTC QLQ BN-20..................................................................................37
14.5
DESCRIPTION OF BIOMARKER ASSAYS .................................................................38
14.5.1
S100.......................................................................................................38
14.5.2
Neuron-specific enolase (NSE).................................................................38
14.6
SOLICITED ADVERSE EVENTS ..............................................................................38
 

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List of Abbreviations
ATA – Atmospheres absolute
DHMC – Dartmouth-Hitchcock Medical Center
EF-5- Hypoxia marker
HBO – Hyperbaric oxygen
HBOT- Hyperbaric oxygen therapy
HIF-1- Hypoxic inducible factor-1
NCCC – Norris Cotton Cancer Center
OER – Oxygen enhancement ratio
SCC- Squamous cell carcinoma
SRS – Stereotactic radiosurgery
WBRT – Whole Brain Radiation Therapy

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Study Summary
Title
Proof-of-principle study of hyperbaric oxygen (HBO) as 
a radiosensitizer prior to stereotactic radiosurgery 
(SRS) for brain metastases
Short Title
HBO-SRS for brain metastases
Protocol Number
D12129
Phase
Proof of principle
Methodology
Open label
Study Duration
5 years
Study Center(s)
Single center (Radiation Oncology section of the NCCC at 
DHMC)
Objectives
To demonstrate that coordination of HBO with SRS 
treatments is feasible.  
To demonstrate that outcomes for patients treated with 
combination of HBO and SRS are non-inferior to historical 
controls.  
Number of Subjects
20 evaluable participants
Diagnosis and Main 
Inclusion Criteria
Patients with brain metastases referred for SRS
Study Product, Dose, 
Route, Regimen
Hyperbaric oxygen given at 2.4 ATA for 30 minutes 
immediately prior to SRS
Duration of 
administration
HBOT for 30 minutes
Reference therapy
SRS without prior HBO
Statistical Methodology
Prospective Phase-I trial (“proof-of-principle”) with matched 
historical controls

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1
Introduction
This document is a protocol for a human research study. This study is to be conducted 
according to US and international standards of Good Clinical Practice (FDA Title 21 part 
312 and International Conference on Harmonization guidelines), applicable government 
regulations and institutional research policies and procedures. 
1.1
Background
Hyperbaric oxygen (HBO) treatment, in which patients breathe 100% oxygen at a high 
ambient atmospheric pressure, is an appealing strategy for overcoming tumor hypoxia. 
HBO dramatically increases the oxygen dissolved in blood plasma, which in turn 
increases oxygen delivery to tissue. 
Radiation therapy is the standard of care for the treatment of many malignancies, 
including brain metastases.  Its mechanism of action includes interaction with dissolved 
molecular oxygen, formation of oxygen radicals, and consequent damage of nuclear 
DNA.  For this reason, hypoxic tissues are less sensitive to radiation damage, both in vitro 
and in vivo (Figure 1, Figure 2).  This increase in radiation sensitivity is quite profound:  
two- to three-fold between hypoxic and oxic tissues (an “oxygen-enhancement ratio” – 
OER – between 2 and 3)  (Figure 1).  In contrast, oxygen’s radiation sensitizing effect 
flattens at higher pO2 levels, with little additional sensitization above pO2 levels of 20-30 
mm Hg  (Figure 3).
Figure 1.  Oxygen enhances radiosensitivity of cells growing in vitro.  From Hall 2012, 
page 88 [1].

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Figure 2.  Oxygen enhances radiosensitivity of cells irradiated in vivo.  The “Air Curve” 
represents data for cells from tumors irradiated in mice breathing air (a mix of hypoxic 
and oxic cells).  The “Hypoxic Curve” represents data for cells from tumors irradiated in 
mice breathing pure nitrogen (all cells hypoxic).  The “Oxic Curve” is for cells irradiated 
in vitro in oxygen (all cells oxic).  From Hall 2012, page 95 (data courtesy of Dr. Sara 
Rockwell – see citations listed in Hall) [1].

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Figure 3.  Dependence of radiosensitivity on oxygen concentration, as summarized by 
Eric Hall.  Note that most of this change in radiosensitivity arises between 0 and 30 mm 
Hg.  There is virtually no additional sensitization at p02 levels above 155 mm Hg (normal 
levels in air).  From Hall 2012, page 90 [1].
Thus, HBO offers the potential advantage of increasing the radiation sensitivity of hypoxic 
tissues (e.g. tumors with poor blood supply) by raising their pO2 levels (even if only by a 
relatively small amount, increasing radiosensitivity disproportionately), while having little 
additional effect on surrounding normal tissues. These normal tissues have normal 
oxygenation and blood supply, so suffer little additional radiosensitivity if their pO2 levels 
are increased.
Experimental data support the potential radiosensitizing effect of HBO in intracranial 
tumors (characterized by large hypoxic fractions) while having little effect on normal 
tissues (with normal oxygen levels).  Four clinical trials have evaluated the radio-
sensitizing potential of hyperbaric oxygen in malignant gliomas. This technique was found 
to be feasible [2], involved minimal toxicity on normal tissues [3, 4], and improved 
outcomes [5, 6].  A recent review of hyperbaric oxygen as a radiosensitizer concluded, 
“… given the findings of improved tumor control and mortality…, there is a case for large 
randomized trials of high methodological vigor…” [7].
Although HBO has been studied in conjunction with XRT in the treatment of primary brain 
tumors, no prior study has examined the role of HBO in combination with XRT in the 
treatment of tumors (“secondary”) metastatic to the brain.  Furthermore, no prior study 
has studied HBO in conjunction with stereotactic radiosurgery (SRS).  
Characterized by the delivery of millimeter-accurate, high-dose radiation therapy in a 
single fraction to a small volume of target tissue, SRS is the standard of care for the 

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treatment of small brain metastases. It is safe and efficacious in a wide variety of clinical 
situations. Local control rates at one year following SRS range from 50-90%, with tumor 
size a significant prognostic factor (Figures 4 and 5).
Figure 4.  Kaplan-Meier analysis of freedom-from-local recurrence (LR) stratified by tumor 
size for a large population of patients with intact brain metastases treated with SRS [8].

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Figure 5.  Kaplan-Meier analysis of freedom-from-local recurrence (LR) stratified by pre-
operative tumor diameter at 3.0 cm:  recent DHMC experience [9].  
Table 1.  One-year and two-year outcomes stratified by tumor size:  recent DHMC 
experience [9].
In this trial we will use hyperbaric oxygen as a radiosensitizer prior to stereotactic 
radiosurgery (SRS) for brain metastases. We hypothesize that reducing tumor hypoxia 
with HBO will increase the sensitivity of these tumors to SRS, that this clinical benefit 
should increase with lesion size, and that no significant radiosensitizing effect of HBO will 

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arise in the surrounding normal brain tissues.
We postulate these hypotheses due to several well-known laboratory phenomena, as 
demonstrated in the research studies of Prof. Swartz (co-investigator on this project) and 
of other investigators:  

tumors are hypoxic;   

HBO increases tissue oxygenation;

increasing pO2 levels above hypoxic levels (pO2 >3 mm Hg) increases 
radiosensitivity with an OER between 2 and 3; 

this OER effect flattens above 20-30 mm Hg (limiting toxicity in normal tissues).
Several clinical observations also support these hypotheses:  

SRS delivers dose with millimeter accuracy to target tissues, limiting normal 
tissue toxicity; 

efficacy of SRS for tumors metastatic to the brain decreases when treating 
larger metastases – for example, >30% local recurrence risk at one year after 
SRS for lesions >3 cm in diameter versus <20% for lesions <2 cm [8] (Figure 
4);  

efficacy of SRS decreases when treating larger resected lesions – for example, 
DHMC experience demonstrated 51% local control rate observed at two years 
for resected lesions with diameters greater than 2.0 cm versus 100% local 
control rate observed for diameters less than 2.0 cm [9] (Table 1).  
If effective, this innovative approach to the treatment of brain metastases may offer 
patients improved tumor control and quality of life without increased treatment risks.
1.2
Investigational Agent
Hyperbaric oxygen treatment given at 2.4 ATA for 30 minutes followed by 
radiation therapy 
Hyperbaric oxygen is oxygen under pressure delivered within a specially designed 
chamber (hyperbaric chamber). During hyperbaric treatment the patient receives oxygen 
while resting supine inside the hyperbaric chamber. This increases the oxygen content of 
blood markedly, not by increasing hemoglobin saturation, since hemoglobin is already 
highly saturated breathing room air, but by increasing the oxygen dissolved in blood 
plasma. This increase in partial pressure of oxygen (pO2) in blood increases the pO2 
commensurately within both normal and tumor tissues.
1.3
Preclinical Data
As discussed in Section 1.1, over the past five decades molecular oxygen has been 
proven to be a powerful modifier of cellular radiation sensitivity [10]. The cytotoxic effect 
of ionizing radiation is increased three-fold when irradiation is performed under well-
oxygenated conditions compared to anoxic conditions (the “oxygen-enhancing ratio” or 
OER) [11]. 

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1.4
Clinical Data
Recent reviews have summarized the use of hyperbaric oxygen as a radiation sensitizer 
[7, 12, 13].  
Several investigators have demonstrated hypoxic regions within brain tumors of patients 
[14-16].  Likewise, many studies have demonstrated significant hypoxia within both 
primary and metastatic tumors in a wide variety of animal and human models.
HBO treatment addresses this issue. Intratumoral oxygen levels remain elevated for 
about 30 minutes after exposure to hyperbaric oxygen; however, intratumoral p02 in the 
presence of 100% normobaric oxygen does not increase either intra- or peritumoral p02 
[17]. 
Older clinical studies of HBO as radiosensitizer demonstrated positive results. For 
example, in 1997 Machin and colleagues summarized 30 years of the U.K.’s Medical 
Research Council trials of solid tumors, an experience that included five trials comparing 
standard therapy in air against standard therapy in hyperbaric oxygen [18].  Of these five 
trials, two demonstrated highly significant advantages for patients receiving HBO (both 
studies in head-and-neck cancer), two did not demonstrate a significant survival 
advantage for HBO (one bladder and one cervix trial), and one demonstrated a strong 
trend for a survival advantage for HBO (also in cervical cancer patients).  The authors 
concluded:  “Thus, the five trials of HBO, when taken together, established a conclusive 
survival advantage over standard radiotherapy in air and give a pooled HR [hazard ratio] 
= 0.80 (95% CI 0.68-0.94).”  
Conducted in the mid-1970s, a trial of 48 head-and-neck cancer patients at Yale-New 
Haven randomized subjects to receive radiotherapy with or without HBO [19].  Although 
interpretation of the results was severely limited due to several technical factors, including 
the use of large radiation fraction sizes (two fractions of 12.65 or 11.70 Gy, the former 
without HBO, the latter with HBO), long-term outcomes demonstrated a highly significant 
difference in complete clinical response with the addition of HBO (even in combination 
with the lower XRT dose):  21/25 in the HBO arm, 13/25 in the control arm.  Long-term 
severe late complications were not significantly different between the two groups (though 
excessive in both arms, due to the large fraction sizes).  This study exemplifies the 
difficulties of most early trials of HBO: poor radiotherapy techniques confounded potential 
improvements in outcomes [13].   
More recent trials using hyperbaric oxygen prior to radiation therapy have shown 
promising results. In a non-randomized study in 1999, Koshi et al. demonstrated improved 
median survival in patients with high-grade gliomas who received hyperbaric oxygen prior 
to radiation compared to patients who were treated with standard radiation therapy and 
chemotherapy alone (24 months versus 12 months) [20]. Beppu et al. studied hyperbaric 
oxygen prior to radiation therapy in patients with malignant high-grade gliomas who were 
also treated with interferon-beta and nimustine hydrochloride. Progression-free survival 
in their patients with glioblastoma multiforme was 9.5 months, which compares favorably 
with the 6.9 months in a recent trial of temozolomide combined with radiation therapy [3]. 

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Ogawa et al. recently published long-term follow up data from their successful Phase II 
trial which ran from 2000-2006 [6].
In a 2007 review of hyperbaric oxygen as a radiation sensitizer, Overgaard concluded, 
“…ample data exist to support a high level of evidence for the benefit of hypoxic 
modification [21].”  In a recent meta-analysis of HBO in head-and-neck trials [11] 
Overgaard found the odds ratio between HBO and control treatments to be 0.46 (CI 0.33-
0.64, p<0.001).
In a contemporary Phase-I multi-institutional trial studying the addition of HBO as 
radiosensitizer for the treatment of head-and-neck cancer, currently reported in abstract 
form [22], DHMC established a successful record for coordinating HBO with fully 
fractionated radiation delivery (average time from chamber to “beam on” of approximately 
8 minutes), in conjunction with standard radiation doses delivered five days a week over 
seven weeks.  No excess toxicity was observed among these patients.  
Extending this experience, our current study will explore the safety of the novel 
combination of HBO followed by SRS for brain metastases.
1.5
Dose Rationale and Risk/Benefits.
Dose Rationale: Hyperbaric oxygen will be given at 2.4 ATA, the dose that was used 
previously in our phase I head and neck cancer study.  This is the dose of oxygen 
generally used for the treatment of radiation complications. Also, this dose is consistent 
with the doses used in several previous studies, although this level is not as high as was 
used in some of the prior glioma studies (2.8 ATA).  In short, this dose has been shown 
in our own work and that of others to be safe.
Risks: The main risks of hyperbaric oxygen therapy are barotrauma to the ear, 
claustrophobia, and oxygen-induced seizures. Ear barotrauma, if it occurs, is not life 
threatening and resolves with time. Patients with claustrophobia requiring treatment will 
be offered lorazepam to help with confinement anxiety and will have the opportunity to 
experience the hyperbaric chamber prior to the treatment day. Patients are at small risk 
for increased seizure activity since high oxygen levels can produce seizures, although 
usually at levels higher than planned for this study. For the level of oxygen used in this 
study (2.4 ATA) the incidence in the general population receiving HBOT is about 0.06% 
or 6 per 10,000 dives [23].
HBO may also contribute to the risk of radiation-related complications.  In his review and 
meta-analysis of hypoxic modification of radiotherapy in head-and-neck cancer patients, 
Overgaard identifies eight trials that studied HBO in comparison to normal treatment 
controls.  These showed a significant increase in the risk of radiation-related 
complications, with an odds ratio of 2.43 (CI 1.43-4.12, p<0.01).  However, Overgaard 
hastens to add that the late tissue damage observed with HBO arose in trials where the 
radiation technique was – even absent HBO – known to have a relatively high likelihood 
of late toxicity; and the difference in some of the trials was further exacerbated by 
administering high doses per fraction in the HBO arm but conventional doses per fraction 

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in the control arm, further confounding the results.  Overgaard concludes, “Consequently, 
there is no definitive evidence of any excess morbidity associated with the [HBO] hypoxic 
modification itself…” [11]  
Risk/Benefit Summary: This is a study for patients with brain metastases. These patients 
are at significant risk for tumor recurrence. Treatment options for these patients are 
limited. The results of this investigation may provide information for improved treatment 
of other patients with this disease. Treatment with hyperbaric oxygen is safe, but 
nevertheless there is the very small risk for seizures and barotrauma to the ear.  Also, the 
theoretical potential risk exists that the combination of HBO with radiation therapy may 
increase late tissue damage from radiation exposure – although there is no solid clinical 
evidence of this potential risk, while there is good radiobiological data that HBO does not 
contribute significantly to the radiation sensitivity of tissues that are already well-
oxygenated, such as normal brain.
2
Study Design
2.1
General Design
This is a Proof of Principle study of hyperbaric oxygen as a radiation sensitizer prior to 
radiosurgery for brain metastases.
2.1.1
Study Objectives
Primary Objective:  To demonstrate that coordination of HBO with SRS treatments is 
feasible.
Secondary Objective:  To demonstrate that outcomes for HBO combined with SRS 
treatment are non-inferior to historical controls.
2.1.2
Study Flowchart
The duration of the study is 5 years.  The study flowchart encompasses three sequential 
phases for each participant:  (1) pre-treatment preparations for both HBO and SRS, (2) 
treatment with HBO immediately followed with SRS; (3) post-treatment follow-up including 
history and physical exam, brain MRI, and QOL instruments initially 4 to 6 weeks after 
treatment and then every 3 months for a minimum of 1 year.  See Figure 6.
Figure 6. Study Flowchart

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Enrollment, CT 
simulation, 
HBO 
familiarization
Treatment 
with SRS and  
2.4 ATA HBO 
(prior to SRS)
Periodic 
follow-up 
visits including 
H+P, MRI, and 
QOL for at 
least 1 year
2.2
Primary Study Endpoints
Demonstrate that coordination of HBO with SRS treatments is feasible.
For HBO sensitization of SRS patients to be feasible, patients must receive radiation 
treatment within a time frame in which pO2 levels are meaningfully elevated.  Since 
intratumoral oxygen levels within the brain remain elevated for about 30 minutes after 
exposure to hyperbaric oxygen [17], feasibility of HBO-SRS treatment requires that a 
patient at least begin SRS within 30 minutes of leaving the HBO chamber.  Evaluation of 
the ability to achieve this goal will be the primary study endpoint.  We will measure time 
from end of “dive” to start of SRS treatment.  Goal will be to achieve “beam on” within 15 
minutes of leaving the chamber.  Total time for treatment to one isocenter (from first arc’s 
beam-on to last arc’s beam-off) using SRS in this study is estimated at 10 minutes (three 
SRS arcs, each 2 minutes, plus set-up time between the first and second and between 
the second and third arcs, each 2 minutes, totaling 10 minutes).  We anticipate a learning-
curve as HBO and therapy staff to develop skill sets for optimizing time across the various 
steps of the procedure:
•
Leaving the HBO chamber 
•
Fitting the - VisionRT open face mask system 
•
Positioning the patient on the table 
•
Imaging the patient to confirm position
•
Reviewing/approving images for treatment
2.3
Secondary Study Endpoints
Demonstrate that outcomes for HBO combined with SRS treatment are non-inferior 
to historical controls.
Secondary endpoints will include:
•
Symptomatic treatment toxicity.  Every patient who receives treatment on this 
protocol will be evaluated for solicited adverse events.  “Solicited adverse 
events” are predefined side effects/medical occurrences identified by the PI 
and co-PIs to be potentially related to intracranial SRS and/or HBO treatments. 
These are enumerated in Attachment 14.6.  These will be graded using the 

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Common Toxicity Criteria Adverse Events (CTCAE) v4.0 of the National 
Cancer Institute.  These will be analyzed in one of two categories:
o
Acute toxicities

Neurological toxicities

Other toxicities
o
Chronic toxicities

Neurological toxicities

Other toxicities

Radiographic evidence for radionecrosis/treatment effects in normal tissue, as 
defined by review/analysis by diagnostic radiologist of follow-up MRI imaging

Incidence of whole brain radiation therapy (WBRT)

Incidence of repeat SRS to the index site

Incidence of repeat SRS to a distant site

Local disease recurrence at the treatment site, as defined by review/analysis 
by diagnostic radiologist of follow-up MRI imaging

Distant disease recurrence elsewhere in the brain, as defined by 
review/analysis by diagnostic radiologist of follow-up MRI imaging

Overall survival
Radiographic MRI outcomes will be assessed by a diagnostic radiologist using standard 
criteria for radiation treatment effects and disease recurrence.  Imaging sets will typically 
include T1-weighted sequences (with and without gadolinium), T2- and Flair-weighted 
sequences, and also perfusion, ADC (“apparent diffusion coefficient”), and spectroscopic 
imaging studies.
2.4
Further Exploratory Study Endpoints

Quality of life measures (see attachments)
o
St. Louis University Mental Status Exam (SLUMS)
o
EORTC Quality of Life Questionnaire C-30
o
EORTC Quality of Life Questionnaire BN-20

Serum markers for tissue apoptosis and for neuronal damage
Several different quality-of-life measures following radiation treatment of the brain have 
been validated in large-scale studies internationally.  We will use the EORTC Quality of 
Life Questionnaire-Core 30/Brain Cancer Module-20 (EORTC QLQ-C30/BN20), which 
has been employed in several RTOG and EORTC studies.  (See Attachment 1.)  As 
discussed in RTOG-0825 protocol documentation:
“The EORTC QLQ C-30/BN-20 were developed and validated for use in this 
[brain cancer] patient population.  The QLQ C-30 is a 30-item self-report 
questionnaire that has patients rate the items on a 4-point scale, with 1 “not 
at all” to 4 “very much.”  The instrument measures several domains, 
including physical functioning, role functioning, emotional functioning, 
cognitive functioning, social functioning, fatigue, pain, nausea and vomiting, 
and several single items (dyspnea, insomnia, anorexia, constipation, 

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diarrhea, and financial impact).  The BN-20 consists of 4 scales comprised 
of multiple items (future uncertainty, visual disorder, motor dysfunction, 
communication deficit) and 7 single items (headache, seizures, drowsiness, 
hair loss, itching, difficulty with bladder control, and weakness of both legs).  
The combined instrument takes an average of 8 minutes to complete by 
patients with primary brain tumors [24].”
Several mental status examinations have been used in the literature, with the Mini-Mental 
State Exam (MMSE), dating back more than 30 years, being the most popular.  However, 
the St. Louis University Mental Status (SLUMS) examination has been shown to be more 
sensitive than the MMSE for detecting mild dementia [25], and it is free for academic 
research use, while the MMSE requires a fee.  Hence, we are employing the SLUMS 
exam in this study.
Serum markers for brain metastases responding to radiation treatment have not been 
demonstrated to date, nor have serum markers for radiation damage to normal brain 
tissue been documented.  In this protocol we test two potential markers:  S100 and NSE.  
Exploratory tests of serum markers will be performed following SRS-HBO using these 
markers found to be specific for neuronal damage.  
Apoptosis after SRS has been shown to arise 6 hours after the procedure, to continue up 
to 48 hours, but to decline by 72 hours post-SRS [26].  S100  and NSE are relatively 
specific for neurological injury and have been shown to be potentially useful serum 
markers of early hypoxic brain injury [27].  We hypothesize that these will be elevated 
following SRS (due to damage of normal brain tissue adjacent to tumor targets).  We 
propose to test S100 and NSE levels 24-48 hours after the SRS treatment in a subgroup 
of patients who have separately consented to this portion of the study.  We anticipate that 
such preliminary data may be of interest in their own right, and that they may also be 
useful for further analysis should a larger study be pursued subsequently of SRS and 
HBO treatments for patients with malignant brain lesions.
3
Subject Selection and Withdrawal
3.1
Inclusion Criteria
Patients meeting all the following criteria are eligible for this trial:

Metastatic brain tumor referred to radiation oncology for treatment 

Size of the presenting metastatic lesion up to 5.0 cm diameter

Age > 18 years

Patients must give informed consent indicating they are aware of the 
investigational nature of this treatment

Karnofsky Performance Status > 70% (Zubrod score 0 to 1)

Women of childbearing potential must have a negative serum or urine 
pregnancy test within 14 days  to start of study therapy

CBC and CMP within 30 days to start of study therapy

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
Chest imaging (Chest Xray or Chest CT) within past 12 months, that does not 
show any contraindication to hyperbaric therapy (if patient has had any thoracic 
surgery or other significant event that might have affected the thorax such as 
trauma, pneumothorax, chest tube insertion, pleurodesis, or thoracentesis and 
has not had imaging since that event, then the imaging should be repeated).

Neurosurgery Consult
3.2
Exclusion Criteria
Patients with the following conditions are not eligible to participate in this trial:

Pregnant women or women of childbearing potential without adequate 
contraception. Contraception, which can include abstinence, is required since 
the last menstrual period until completion of SRS. 

Evidence of pneumothorax
o
Untreated pneumothorax risks tension pneumothorax during ascent in 
HBO chamber

COPD with C02 retention
o
Such patients can develop respiratory depression as HBO reduces 
their hypoxemic drive 

Uncontrolled seizure disorder
o
Note that patients on adequate antiepileptic medications may receive 
HBO 

Claustrophobia resistant to medication
o
Pre-medication with anxiolytics is generally sufficient for almost all 
anxious patients undergoing HBO treatment

History of middle ear surgery
o
Failure to equalize pressure in the middle ear can cause displacement 
of middle ear structures with consequent hearing loss
o
To clarify:  placement of a tympanostomy tube is not a contraindication 
to HBO, and in fact may improve tolerability of the procedure

History of bleomycin administration
o
HBO can exacerbate interstitial pneumonitis in such patients

Current cis-platinum chemotherapy (i.e. therapeutic levels in the bloodstream 
at the time of HBO therapy)
o
HBO can increase cytotoxicity of cis-platinum

Uncontrolled high blood pressure
o
HBO can increase systemic vascular resistance

Unstable angina or myocardial infarction within the previous 3 months
o
Increased afterload due to HBO can increase myocardial workload

Cardiac EF ≤ 35%
o
Pulmonary edema can arise with HBO in certain patients with severe 
heart failure 
o
In patients with prior history of CHF, subsequent echocardiogram and 
ECG are required to establish EF>35%

Treatment with disulfiram

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o
Disulfiram inhibits superoxide dismutase and is not approved for use 
concomitantly with hyperbaric oxygen therapy

Active drug/alcohol dependence or abuse

Lack of adequate social support structures, e.g. homelessness

Tumors with potential confounding results on serum marker studies
o
Small cell (neuroendocrine) carcinomas
o
Carcinoid tumors
3.3
Subject Recruitment and Screening
Subjects will be recruited from patients who are potential candidates for SRS treatment 
at DHMC for brain metastases. Such patients are referred to radiation oncology by 
practitioners at DHMC and by physicians at outlying hospitals.  
The patient’s first visit with radiation oncology will serve to screen the patient for most of 
the inclusion and exclusion criteria noted above. If the patient appears to be a candidate 
and wishes to enroll on the protocol, then he/she will be scheduled for a visit with the 
hyperbaric medicine service. At this visit the subject will be screened for any 
contraindications to hyperbaric oxygen therapy, and will be given a chance to visit the 
chamber. 
3.4
Early Withdrawal of Subjects
3.4.1
When and How to Withdraw Subjects
Reasons for treatment discontinuation include: 

Subject request or withdrawal of consent

Subject non-compliance with the protocol

Life-threatening or unacceptable adverse events at time of SRS or HBO 
treatment, such as HBO-induced seizure

Physician judgment in view of subject’s inter-current illness or safety 
considerations

Administrative decision to discontinue the study.
3.4.2
Data Collection and Follow-up for Withdrawn Subjects
The date and reason for subject discontinuation from the study will be recorded. A 
discontinuation occurs when an enrolled subject ceases participation in the study, 
regardless of the circumstances. Withdrawal due to an adverse event will be distinguished 
from withdrawal from the study according to the definition of adverse event. 
Despite the discontinuation, every effort will be made to complete the appropriate 
assessments. The patient will be followed using the standard follow-up procedures for 
patients who receive radiation therapy for brain metastases. 

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3.4.3
Replacement of withdrawn subjects
Patients withdrawn from the protocol as per Section 3.4.1 within one year of enrollment 
will not be deemed as counting towards the enrollment goal of twenty evaluable patients.  
Therefore, another patient (comparable in terms of resection status and tumor size) will 
be enrolled who may serve as a “substitute” for the withdrawn participant.
4
Study Intervention 
4.1
Description
Hyperbaric oxygen given immediately preceding intracranial stereotactic radiosurgery
4.2
Treatment Regimen
Prior to the day of treatment, each patient will receive an orientation to the hyperbaric 
chambers located in the hyperbaric medicine department within radiation oncology.  A 
“test drive” will be performed with the patient in the chamber with air rather than 100% 
oxygen. This will verify the patient’s ability to equalize pressure in the middle ear and will 
assure that he or she is not claustrophobic.  A small percentage of patients (estimated at 
15%, based on prior experience) may be unable to achieve pressure equalization in the 
middle ear.  These patients will be offered placement of a tympanostomy tube to facilitate 
HBO treatment and to enable continuation with the protocol, a simple procedure 
performed typically by a Physician’s Assistant in DHMC’s Section of Otolaryngology.  
On the day of SRS, during HBO treatment the patient will receive oxygen under pressure 
while lying supine inside the hyperbaric chamber.  HBO will be given at 2.4 ATA. 
Compression will occur at 3.77 feet/minute. The patient will stay at depth for 30 minutes.  
Decompression will be performed over a 5-minute time span. 
Patients then will be transported from the HBO chamber via stretcher to the SRS 
treatment area while receiving 100% oxygen via non-rebreather face mask @15L/minute 
to help maintain oxygen saturation.
Patients then will receive radiosurgery for their metastases as detailed below (Section 5.3 
– “SRS Treatment Visit”).
A stopwatch will be used to document the time elapsed from when the patient exits the 
hyperbaric chamber to when he/she starts receiving SRS (“beam-on”).  The goal of this  
time interval should be kept at ≤15 minutes. Elapsed time from leaving the hyperbaric 
chamber to completion of SRS will be recorded as well.
4.3
Acute HBO toxicity
We do not anticipate patients experiencing toxicities in conjunction with their HBO 
treatments.  All will have undergone pre-screening for claustrophobia and barotrauma.  

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The likelihood of a seizure in conjunction with HBO treatment is less than one in a 
thousand (in the general population).  
In the very unlikely event of a tonic-clonic seizure, the chamber will be brought to surface 
after air breaks and after tonic-clonic movements have subsided and regular respirations 
have resumed.  Then the patient will be removed from the chamber and transported to 
the DHMC Emergency Department for further evaluation and management. 
4.4
Prior and Concomitant Therapy
Patients will continue on the medications prescribed by their treating providers. 
Patients who are taking anticonvulsants upon enrollment in the study will continue those 
medications as prescribed. Palliative and supportive care for disease-related symptoms 
will be offered to all subjects enrolling on this trial (which is our standard of care), and 
these will be continued as appropriate during the phases of this protocol.  Details about 
interventions and concomitant medications will be collected.
Treatment with disulfiram is not allowed in this study since disulfiram inhibits superoxide 
dismutase. Patients should not receive cis-platinum chemotherapy just prior to their 
hyperbaric oxygen treatments. 
5
Study Procedures (see attached table, Section 14.1)
5.1
Visit 1 – “Initial consultation visit”
At this “visit” the radiation oncologist screens potential patients, discusses risk/benefits of 
the study with eligible patients, and provides patients with information about the study. 
Patients will also have a consultation with neurosurgery. During this time the study 
consent will be completed (along with any further required screening procedures, 
including blood work).  Although we are considering the consultations with radiation 
oncology and neurosurgery to be part of the same “visit,” for logistical reasons the 
consultations with the radiation oncologist and neurosurgeon may take place on different 
days.  Chest imaging is required (in preparation for HBO to exclude pulmonary 
contraindications) if the patient has not had a chest imaging in the prior year.  We estimate 
25% of patients will require a chest imaging, though it seems likely that in this heavily 
treated cancer population the number will in actuality be lower than this estimate.
Information collected at Visit 1
                  
Inclusion /Exclusion criteria
History and Physical Examination
EORTC Quality of Life C-30 and BN20

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Karnofsky/Zubrod Performance Status
St. Louis University Mental Status Exam
Complete Blood Count (within 30 days of SRS treatment)
Comprehensive Metabolic Profile (within 30 days of SRS treatment)
*Blood sample for biomarkers (pre-TX)
Review of prior MRI of the brain
Pathology confirmation
Pregnancy Test, if applicable (within 14 days of SRS treatment)
Chest imaging, if indicated
*If the patient is enrolled in the biomarker sub-study, a blood draw will be performed prior 
to the HBO and SRS treatments to test NSE and S100 levels.
5.2
Visit 2 – “Pretreatment visit” 
At this “visit” the patient will have a consult for HBO treatment, and then will have a 
practice dive with air in the hyperbaric chamber. The patient will also have a 
radiotherapy-planning MRI, a fitting for the VisionRT open face mask system, and a CT-
based simulation of the SRS treatment for radiation therapy treatment planning. 
Although these items are all considered part of the “pre-treatment visit,” for logistical 
reasons some of the items may be scheduled on different days.
Information collected at Visit 2
                  
HBO consult with “dry run”
RT-planning brain MRI
CT-based RT simulation (including fitting of - VisionRT open face mask)
5.3
Visit 3 – “SRS Treatment Visit”
At this visit the patients will undergo HBO treatment (as detailed in Section 4.2 above), 
followed by radiation therapy (SRS). 
5.3.1
Principles: 
Stereotactic radiosurgery (SRS) requires precise target definition using volumetric (3D 
conformal) techniques.  Treatment delivery is accomplished with millimeter-precision 
through the combination of precise pre-treatment MRI imaging, accurate image co-
registration of planning MRI scans and CT-simulation datasets, and precise frame-based 
treatment with image-guidance on the linear accelerator at time of treatment delivery.
5.3.2
Equipment: 
Accelerator x-ray beams (photons) with nominal energy of at least 4 MV and not greater 
than 20 MV. The accelerator must have available cone-beam CT (CBCT) imaging 
capabilities to assure accurate set-up at the time of treatment delivery.  

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5.3.3
Protocol Volume Target Definitions:
All treatment planning will be based upon the following target definitions. Treatment will 
be prescribed to the PTV, which will be derived from the GTV, as follows:
5.3.4
Gross Tumor Volume (GTV): 
This is the volume occupied by radiographically visible disease as per postoperative and 
pre-irradiation MRI. The T1-MR image with contrast is usually the optimal imaging study. 
Appropriate fusion of the MRI with the planning CT scan is required for accurate treatment 
delivery.
5.3.5
Planning Target Volume (PTV):
The PTV accounts for uncertainties in imaging, registration, and patient set-up, and also 
incorporates the potential for microscopic disease extension.  For unresected metastases 
treated in the VisionRT open face mask, the additional margin from GTV to PTV will be 2 
mm in all dimensions.  For resected metastases treated in the VisionRT open face mask, 
the additional margin will be 3 mm in all dimensions.
5.3.6
Timing of Radiotherapy:
Radiation therapy will be delivered following the patient’s exit from the HBO chamber.  
Every effort will be made to begin radiation treatment within 15 minutes of the patient’s 
exit from the chamber.  The time between exit from the chamber and beam-on will be 
recorded as part of the patient’s treatment record.
5.3.7
Target Dose:
In general, the target dose to the margin of the PTV will be prescribed as per RTOG 90-
05, which is considered the current standard of care [28].  However, the target dose may 
be modified to respect normal tissue tolerances (see below), as per clinical judgment of 
the prescribing radiation oncologist and the consulting neurosurgeon:
Target diameter
Dose to target margin
Up to 2.0 cm
20 Gy
2.1 – 3.0 cm
18 Gy
3.1 – 4.0 cm
15 Gy
4.1 – 5.0 cm
12 Gy
5.3.8
Normal Tissue Tolerance:
Dose prescriptions will take into account the tolerances of surrounding normal tissues, 
such as brainstem, optic nerves, optic chiasm, and motor cortex.  Target dose to the 
margin of the PTV may be modified to avoid excess dose to such sensitive tissues, per 
the clinical judgments of the prescribing radiation oncologist and the consulting 
neurosurgeon.   
5.3.9
Optional Blood Draw for Markers
If the patient is enrolled in the blood marker sub-study, a blood draw will be performed 
the day following the SRS treatment.

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5.4
Follow-up visits
At each of these visits, the patient will undergo a follow-up MRI scan (with sequences 
including dynamic susceptibility contrast (DSC) perfusion, apparent diffusion coefficient 
(“ADC”), and single voxel proton MR spectroscopy if radionecrosis and/or local tumor 
recurrence is suspected on the standard MRI sequences) as well as history and physical 
exam with the radiation oncologist.  Bloodwork will be drawn at the first follow-up visit 
(including CBC, CMP, and biomarkers (for participating patients only).
These visits will occur at the following intervals:
Optional follow-up visit for blood marker study – Day after SRS
First follow-up visit (“Visit 4”) – 4-6 weeks after SRS;
Visits 5 through 12 – at 3-month intervals after the initial follow-up till the conclusion of 
the study (two years following SRS).
Further follow-ups (off-protocol) will continue as per standard of care:
Visits 13 through 15 – at 4-month intervals after Visit 12;
Visits 15 through 18 – at 6-month intervals after Visit 15;
Visits 19+ – annual follow-up visits after Visit 18.
Information collected at each follow-up visit 
                  
History and Physical Examination 
EORTC QLQ C-30 and BN-20
St. Louis University Mental Status Exam
MRI of the brain
(Plus bloodwork drawn at Visit 4 including CBC, CMP, and biomarkers) 
6
Statistical Plan
6.1
Statistical Methods
For the primary outcome variable of feasibility, the twenty evaluable patients will be 
analyzed on the basis of the amount of time required from leaving the HBO chamber to 
beginning SRS for the target lesion (T1).
The goal for each patient (as discussed in Section 2.2) is for T1 to be no greater than 15 
minutes. In a Phase I trial of HBO treatment in coordination with fully fractionated head-
neck cancer XRT, DHMC established a track-record of an average of only eight minutes 
from time of leaving the HBO chamber to “beam on” for this patient group [22].  However, 
set-up for SRS treatment is more complex, involving placement of a head-frame and 
performance of a CT-scan prior to SRS treatment.  These may extend the time interval 
required for patient set-up after leaving the HBO chamber.
We anticipate a learning curve for the team members of this study.  Therefore, stopping 
rules are as outlined in Section 7.4:  no more than 20% of first ten patients treated within 

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30 minutes of HBO; and no more than 33% of first fifteen patients treated within 30 
minutes of HBO.
The primary endpoint of feasibility is defined as having been achieved if more than 50% 
of the 20 evaluable patients start SRS treatment within 30 minutes of leaving the HBO 
tank:  in other words, T1 is <=30 minutes for >50% of evaluable patients.
For the secondary endpoints, using Cox proportional hazards models, and Kaplan-Meier 
survival statistics, the overall group of 20 will be analyzed for event-free survival and 
compared against a matched set of patients from our institution (see below for 
methodology).  This match will be based on tumor size, resection status, and histology-
specific graded prognostic assessment (GPA).  The GPA is a validated, widely accepted 
prognostic scale predictive of survival for patients presenting with brain metastases.  
Diagnosis-specific GPA calculation is based on published criteria including tumor 
histology, presence of systemic metastases, number of brain metastases, age, 
performance status, and breast-cancer specific molecular markers [29-31]. Further 
demographic and treatment data will also be collected, including:  gender, subtotal 
resection versus gross total resection (if tumor resected), tumor diameter (prior to first 
treatment, whether surgery or SRS), SRS target volume (PTV), and prescribed dose to 
the PTV.  The secondary outcome variables will be the first occurrence of the event of 
interest and also the time until the first occurrence of the event of interest.  These events 
include:  intracranial recurrence at SRS site, intracranial recurrence at a distant site, 
whole brain XRT, second SRS (classified as either local or distant), third SRS (classified 
as local or distant), radionecrosis at the SRS site, and death.        
A retrospective database pertaining to Dartmouth-Hitchcock’s experience with 
stereotactic radiosurgery in the treatment of brain metastases is being collected through 
Study 00030625 (PI Greg Russo, MD).  Pertinent matching variables, along with 
demographic variables, treatment variables, and outcome variables for the control 
population are available on 00030625.  The matching variables (histology, lesion size, 
resection status, and calculated GPA) will be used to identify a control population in the 
Study 00030625 that match 1:1 against the D12129 enrolled patient population.  
Specifically, patients with similar tumor histologies will be matched against histologies 
found in the D12129 patient population, falling into one of six categories:  (1) non-small 
cell lung cancer, (2) melanoma, (3) breast cancer, (4) renal cell cancer, (5) GI cancers, 
and (5) other histologies.  Once a histologic match is identified, the patient is then 
matched by resection status (either unresected or resected).  The third matching variable 
is then GPA.  If an exact GPA match is not available in the 000030625 data base, then a 
patient with a higher GPA will be selected, with the control patient’s GPA as near as 
possible to that of the corresponding D12129 patient (thereby, if anything, biasing the 
survival outcome data slightly against the D12129 data set).  Lastly, the fourth matching 
variable is tumor size (i.e. maximum tumor diameter) at time of treatment (a categorical 
variable, either below or above 2.0 cm).  If an exact match for the fourth variable is not 
available in the 000030625 data base, then size will be matched as closely as possible 
to the 2.0 cm cut-off from those patients available in this historical database.  These 

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matching patients identified in 000030625 data base will serve as the control group for 
the D12129 study.   
Once the control group patients have been selected, their data will be extracted from the 
00030625 database in de-identified form. These data will be reviewed by an “honest 
broker” to assure proper de-identification and HIPAA compliance.   These de-identified 
control group data will then be merged with the D12129 dataset. Analysis of this combined 
data base then will allow comparison of HBO-treated and control patients in terms of 
event-specific outcome parameters, with events including:  death, local intracranial 
recurrence, distant intracranial recurrence, whole brain radiation therapy, and repeat SRS 
(either local or distant). 
Exploratory variables will include QOL data and tumor markers. Comparisons for change 
in markers before versus after HBO-SRS treatment will be performed for the entire group 
of twenty patients.  Also comparisons will be performed for subgroups (including 
comparisons of those with resections versus those without, and of those above 2.0 cm 
diameter versus those below).
Time line for completion of the study is 5 years.  We anticipate accrual of the 20 patients 
in the first three years (0-36 months).  Follow-up is anticipated to be a minimum of one to 
two years for each surviving patient (13-48 months). Manuscript preparations and 
submissions should occur in the fourth and fifth years (48-60 months).
6.2
Sample Size Determination
For the initial phase of this study we anticipate enrolling 20 patients (DHMC treats about 
80-100 SRS patients yearly):  5 with resected lesions up to 2.0 cm (diameter), 5 with intact 
lesions up to 2.0 cm, 5 with resected lesions greater than 2.0 cm, and 5 with intact lesions 
greater than 2.0 cm. Based on a median event-free survival time of 6 months in the control 
group, a log-rank test with a one-sided significance level of 0.05 and a power of 0.80 can 
detect a relative risk of 0.39 or smaller.  Thus, we have sufficient power to detect 61% 
increase in the risk of toxicity, recurrence or death.
6.3
Subject Population(s) for Analysis
The study population will be any subject enrolled in the study.
7
Safety and Adverse Events
7.1
Definitions
Unanticipated Problems Involving Risk to Subjects or Others
Any incident, experience, or outcome that meets all of the following criteria: 

Unexpected in nature, severity, or frequency  (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators 
brochure, etc)

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
Related or possibly related to participation in the research (i.e. possibly related 
means there is a reasonable possibility that the incident experience, or outcome 
may have been caused by the procedures involved in the research)

Suggests that the research places subjects or others at greater risk of harm 
(including physical, psychological, economic, or social harm).
Adverse Event
An adverse event (AE) is any symptom, sign, illness or experience that develops or 
worsens in severity during the course of the study. Inter-current illnesses or injuries 
should be regarded as adverse events.  Abnormal results of diagnostic procedures are 
considered to be adverse events if the abnormality:

results in study withdrawal

is associated with a serious adverse event

is associated with clinical signs or symptoms

leads to additional treatment or to further diagnostic tests

is considered by the investigator to be of clinical significance
Solicited Adverse Event
A solicited adverse event is any adverse event that has been identified by the PI or co-
PIs as potentially related to intracranial SRS and/or HBO treatments.  Occurrence and 
severity of all solicited adverse events will be catalogued for all D12129 patients.  These 
are enumerated in Attachment 14.6.
Serious Adverse Event
Adverse events are classified as serious or non-serious.  A serious adverse event is 
any AE that is: 

fatal

life-threatening

requires or prolongs hospital stay

results in persistent or significant disability or incapacity

a congenital anomaly or birth defect

an important medical event
Important medical events are those that may not be immediately life threatening, but are 
clearly of major clinical significance.   They may jeopardize the subject, and may require 
intervention to prevent one of the other serious outcomes noted above.  For example, 
drug overdose or abuse, a seizure that resulted in in-patient hospitalization, or intensive 
treatment of bronchospasm in an emergency department would typically be considered 
serious. 
All solicited adverse events that do not meet any of the criteria for serious will be regarded 
as non-serious solicited adverse events. 
Adverse Event Reporting Period
The study period during which solicited adverse events must be reported is defined as 
the period from the initiation of any study procedures to the end of the study treatment 

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follow-up.  For this study, the study treatment follow-up is defined as the time following 
study treatment until the date of documented death, withdrawal of consent, or the end of 
the study, whichever occurs first.
Preexisting Condition
A preexisting condition is one that is present at the start of the study.  A preexisting 
condition will be recorded as  a solicited adverse event if the frequency, intensity, or the 
character of the condition worsens during the study period.
General Physical Examination Findings
At screening, any clinically significant abnormality will be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities 
that meet the definition of an adverse event must also be recorded and documented as 
an adverse event. 
Post-study Adverse Event
All unresolved solicited adverse events will be followed by the investigator until the events 
are resolved, the subject is lost to follow-up, or the solicited adverse event is otherwise 
explained.  At the last scheduled visit, the investigator will instruct each subject to report 
any subsequent event(s) that the subject, or the subject’s personal physician, believes 
might reasonably be related to participation in this study.  The investigator will notify the 
study sponsor of any death or adverse event occurring at any time after a subject has 
discontinued or terminated study participation that may reasonably be related to this 
study.  The sponsor will also be notified if the investigator becomes aware of the 
development of cancer or of a congenital anomaly in a subsequently conceived offspring 
of a subject that has participated in this study. 
Abnormal Laboratory Values
A clinical laboratory abnormality will be documented as an adverse event if any one of 
the following conditions is met: 

The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality

The abnormality suggests a disease and/or organ toxicity

The abnormality is of a degree that requires active management; e.g. change of 
dose, discontinuation of the drug, more frequent follow-up assessments, further 
diagnostic investigation, etc.
Hospitalization, Prolonged Hospitalization or Surgery
Any solicited adverse event that results in hospitalization or prolonged hospitalization will 
be documented and reported as a serious adverse event unless specifically instructed 
otherwise in this protocol.  Any condition responsible for surgery will be documented as  
a serious adverse event if the condition meets the criteria for  a solicited adverse event. 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery will be 
reported as an adverse event in the following circumstances:

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
Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition.  Surgery should not be reported as an 
outcome of an adverse event if the purpose of the surgery was elective or 
diagnostic and the outcome was uneventful.

Hospitalization or prolonged hospitalization required to allow efficacy measurement 
for the study.

Hospitalization or prolonged hospitalization for therapy of the target disease of the 
study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator.
7.2
Recording of Adverse Events
At each contact with the subject, the investigator will seek information on solicited adverse 
events by specific questioning and, as appropriate, by examination.  Information on all 
solicited adverse events will be recorded immediately in the source document, and also 
in the appropriate adverse event module of the case report form (CRF).  All clearly related 
signs, symptoms, and abnormal diagnostic procedures results should recorded in the 
source document, though should be grouped under one diagnosis. These will be graded 
using the Common Toxicity Criteria Adverse Events (CTCAE) v4.0 of the National Cancer 
Institute.  Retrospective review of patient charts will be employed to assure accurate 
recording of solicited adverse events.  Any additional solicited adverse events identified 
by such retrospective review will be incorporated into the data base and included in the 
analysis.
All solicited adverse events occurring during the study period will be recorded.  The 
clinical course of each event will be followed until resolution, stabilization, or until it has 
been determined that the study treatment or participation is not the cause.  Serious 
adverse events that are still ongoing at the end of the study period will be followed up to 
determine the final outcome.  Any serious adverse event that occurs after the study period 
and is considered to be possibly related to the study treatment or study participation will 
be recorded and reported immediately.
7.3
Reporting of Serious Adverse Events and Unanticipated Problems
Adverse events that will be reported are those that are:

At least possibly related to study participation,

unexpected, and 

serious or involve risks to subjects or others 
(see definitions, section 7.1).  
The following information will be included in the adverse event report initial report:

Study identifier

Subject number

A description of the event

Date of onset

Current status

Whether study treatment was discontinued

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
The reason why the event is classified as serious

Investigator assessment of the association between the event and study treatment
7.3.1 Investigator reporting: notifying the IRB
Serious adverse events will be reported to the Dartmouth-Hitchcock Health (D-HH) IRB 
as required per IRB and institutional policy. 
7.4
Stopping Rules 
An internal stopping rule is set in place whereby the study will be terminated if (1) 
feasibility appears unattainable, or (2) a significant number of patients experience a 
significant adverse event (SAE) as outlined above:

Regarding the primary endpoint of feasibility, we anticipate a steep learning curve 
for treatment of patients on this trial.  The overall goal is to begin SRS within 15 
minutes of exiting the HBO chamber; however, it is known that oxygen levels 
remain elevated in the brain up to 30 minutes after HBO treatment.  The following 
stopping rules will be applied:
o
Analysis after enrollment of first 10 patients demonstrates no more than two 
patients (20%) treated within 30 minutes of HBO chamber exit.
o
Analysis after enrollment of first 15 evaluable patients demonstrates no 
more than five patients (33%) treated within 30 minutes of HBO chamber 
exit.

Regarding the secondary endpoint of noninferiority, every patient who receives 
treatment on this protocol will be evaluated at every patient encounter for adverse 
events. Toxicities will be graded using the Common Toxicity Criteria Adverse 
Events (CTCAE) v4.0 of the National Cancer Institute.  
o
Overall incidence of adverse events in this study will be reviewed every 
three months.
o
At time of any such review, if more than 40% of enrolled patients (minimum 
of 5 patients) experience SAEs that are deemed likely related to the protocol 
treatment (HBO combined with SRS), then the study will be terminated (i.e. 
more than 2 out of 5 patients, or more than 4 out of 10 patients, for 
example).  
o
Note that some SAEs are expected in this patient population, given the 
nature of the disease process that is being treated.  The stopping rule of 
40% was elected as representing an incidence level significantly higher than 
that expected routinely in this patient population.

It is the responsibility of the Principal Investigator to oversee the safety of the study.  
This safety monitoring will include careful assessment and appropriate reporting of 
adverse events as noted above, as well as quarterly review by the Norris Cotton 
Cancer Center Data and Safety Monitoring and Accrual Committee (see section 9 
Auditing, Monitoring and Inspecting).  Medical monitoring will include a regular 
assessment of the number and type of serious adverse events.

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8
Data Handling and Record Keeping
8.1
Confidentiality
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 
Participants will sign an authorization that includes the following:
 
 What protected health information (PHI) will be collected from subjects in this study
 Who will have access to that information and why
 Who will use or disclose that information
 The rights of a research subject to revoke their authorization for use of their PHI.
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of 
subject authorization.
 
Loss of patient confidentiality is a risk of participation.  Study participant identities will be 
kept confidential except as required by law.  Subjects’ samples will be identified by code 
only (i.e. linked, but de-identified).  Patient samples will be de-identified at the time and 
site of collection.   Electronic case report forms, participant, and study information will be 
kept in the Velos eResearch password protected database.  Additionally, documents 
containing participant identifiers, such as those from the medical record to confirm 
eligibility, will be filed in binders and kept in a locked, secure location in the Office of 
Clinical Research at the Norris Cotton Cancer Center.
8.2
Source Documents
Source data are all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  
Source data are contained in source documents.  Examples of these original documents, 
and data records include: hospital records, clinical and office charts, laboratory notes, 
memoranda, subjects’ diaries or evaluation checklists, pharmacy dispensing records, 
recorded data from automated instruments, copies or transcriptions certified after 
verification as being accurate and complete, microfiches, photographic negatives, 
microfilm or magnetic media, x-rays, subject files, and records kept at the pharmacy, at 
the laboratories, and at medico-technical departments involved in the clinical trial.
8.3
Case Report Forms
The study case report form (CRF) is the primary data collection instrument for the study.  
All data requested on the CRF will be recorded.  All missing data will be explained.  If a 
space on the CRF is left blank because the procedure was not done or the question was 
not asked, “N/D” will be entered.  If the item is not applicable to the individual case, “N/A” 
will be entered.  All entries will be printed legibly in black ink.  If any entry error has been 
made, to correct such an error, a single straight line will be drawn through the incorrect 
entry and the correct data entered above it.  All such changes will be initialed and dated.  

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ERRORS WILL NOT BE ERASED OR WHITED OUT.  For clarification of illegible or 
uncertain entries, a clarification will be printed above the item, then initialed and dated.
8.4
Records Retention
Following closure of the study, the investigator will maintain all site study records in a safe 
and secure location.  The records are maintained to allow easy and timely retrieval, when 
needed (e.g., audit or inspection) and, whenever feasible, to allow any subsequent review 
of data in conjunction with assessment of the facility, supporting systems, and staff.  Upon 
completion of study analysis, research information is stored in Dartmouth College 
Records Management off-site storage. Documents are shredded on site after 50 years of 
storage.
 
Electronic case report forms, participant, and study information will be kept in the Velos 
eResearch password protected database indefinitely.
9
Study Monitoring, Auditing, and Inspecting
9.1
Safety and Data Monitoring
This study will be monitored by the Data Safety Monitoring and Accrual Committee 
(DSMAC) of the Norris Cotton Cancer Center.  The Committee meets quarterly to review 
accrual rates and information of all studies that have accrued participants.  The DSMAC 
has the authority to suspend or terminate all research activities that fall within its 
jurisdiction.   In the event that a study is suspended or terminated by the DSMAC, that 
information will be forwarded to the D-HH IRB.
9.2
On-Site Monitoring
Clinical research monitoring will be conducted by appropriately trained staff of Dartmouth-
Hitchcock Medical Center Clinical Trials Office or those of the OCR. This monitoring will 
include periodic assessment of the regulatory compliance, data quality, pharmacy 
records, and study integrity. Study records will be reviewed and directly compared to 
source documents and the conduct of the study will be discussed with the investigator, 
Monitors may request access to all regulatory documents, source documents, CRFs, and 
other study documentation for on-site inspection. Direct access to these documents is 
guaranteed by the investigator, who must provide support at all times for these activities.
9.3
Auditing and Inspecting
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable Dartmouth Research compliance and 
quality assurance offices (The Dartmouth CTO). The investigator will permit study-related 
audits and inspections by the D-HH IRB, government regulatory bodies, and the 
Dartmouth compliance and quality assurance groups (CTO) of all study related 
documents (e.g. source documents, regulatory documents, data collection instruments, 
study data etc.) The investigator will ensure the capability for inspections of applicable 
study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.).

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10 Ethical Considerations
This study is to be conducted according to US and international standards of Good 
Clinical Practice (FDA Title 21 part 312 and International Conference on Harmonization 
guidelines), applicable government regulations and Institutional research policies and 
procedures.
This protocol and any amendments will be submitted, reviewed and approved by the 
Dartmouth-Hitchcock Health (D-HH) IRB prior to conduct of the study or amendment.  All 
subjects for this study will be provided an IRB-approved consent form describing this 
study and providing sufficient information for subjects to make an informed decision about 
their participation in this study.  The consent of a subject, using the IRB-approved consent 
form, must be obtained before that subject undergoes any study procedure.  The consent 
form must be signed by the subject and the investigator-designated research professional 
obtaining the consent. 
11 Study Finances
11.1 Funding Source
This study is funded by the Norris Cotton Cancer Center Clinical Translational Research 
effort.
11.2 Conflict of Interest
The Conflict of Interest Policy on Human Subject Research for Dartmouth-Hitchcock 
Clinic, Mary Hitchcock Memorial Hospital and Dartmouth College found at 
http://www.dartmouth.edu/~cphs/docs/coi-hs-policy.pdf will be followed.  
12 Publication Plan
Neither the complete nor any part of the results of the study carried out under this protocol, 
nor any of the information regarding the performance of the study, will be published or 
passed on to any third party without the consent of the study sponsor, Dr. Hartford.
13 References
1.
Hall, E.J. and A.J. Glaccia, Oxygen Effect and Reoxygenation, in Radiobiology for 
the Radiologist. 2012, Lippincott Williams and Wilkins: Philadelphia, PA.
2.
Ogawa, K., et al., Prospective trial of radiotherapy after hyperbaric oxygenation 
with chemotherapy for high-grade gliomas. Radiother Oncol, 2003. 67(1): p. 63-7.
3.
Beppu, T., et al., A phase II study of radiotherapy after hyperbaric oxygenation 
combined with interferon-beta and nimustine hydrochloride to treat supratentorial 
malignant gliomas. J Neurooncol, 2003. 61(2): p. 161-70.
4.
Ogawa, K., et al., Phase II trial of radiotherapy after hyperbaric oxygenation with 
chemotherapy for high-grade gliomas. Br J Cancer, 2006. 95(7): p. 862-8.

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5.
Kohshi, K., et al., Fractionated stereotactic radiotherapy using gamma unit after 
hyperbaric oxygenation on recurrent high-grade gliomas. J Neurooncol, 2007. 
82(3): p. 297-303.
6.
Ogawa, K., et al., Phase II Trial of Radiotherapy After Hyperbaric Oxygenation 
With Multiagent Chemotherapy (Procarbazine, Nimustine, and Vincristine) for 
High-Grade Gliomas: Long-Term Results. Int J Radiat Oncol Biol Phys, 2012. 
82(2): p. 732-8.
7.
Bennett, M., et al., Hyperbaric oxygenation for tumour sensitisation to 
radiotherapy. Cochrane Database Syst Rev, 2005(4): p. CD005007.
8.
Serizawa, T., et al., Gamma Knife surgery for metastatic brain tumors without 
prophylactic whole-brain radiotherapy: results in 1000 consecutive cases. J 
Neurosurg, 2006. 105 Suppl: p. 86-90.
9.
Hartford, A.C., et al., Postoperative Stereotactic Radiosurgery Without Whole-
Brain Radiation Therapy for Brain Metastases: Potential Role of Preoperative 
Tumor Size. Int J Radiat Oncol Biol Phys, 2012.
10.
Hall, E.J., The oyxgen effect and reoxygenation, in Radiobiology for the radiologist. 
1994, Lippincott: Philadelphia.
11.
Gray, L.H., et al., The concentration of oxygen dissolved in tissues at the time of 
irradiation as a factor in radiotherapy. Br J Radiol, 1953. 26(312): p. 638-48.
12.
Bennett, M., et al., Hyperbaric oxygenation for tumour sensitisation to 
radiotherapy: a systematic review of randomised controlled trials. Cancer Treat 
Rev, 2008. 34(7): p. 577-91.
13.
Overgaard, J., Hypoxic modification of radiotherapy in squamous cell carcinoma 
of the head and neck--a systematic review and meta-analysis. Radiother Oncol, 
2011. 100(1): p. 22-32.
14.
Moringlane, J.R., Measurement of oxygen partial pressure in brain tumors under 
stereotactic conditions. Adv Exp Med Biol, 1994. 345: p. 471-7.
15.
Valk, P.E., et al., Hypoxia in human gliomas: demonstration by PET with fluorine-
18-fluoromisonidazole. J Nucl Med, 1992. 33(12): p. 2133-7.
16.
Kayama, T., et al., Intratumoral oxygen pressure in malignant brain tumor. J 
Neurosurg, 1991. 74(1): p. 55-9.
17.
Beppu, T., et al., Change of oxygen pressure in glioblastoma tissue under various 
conditions. J Neurooncol, 2002. 58(1): p. 47-52.
18.
Machin, D., et al., Thirty years of Medical Research Council randomized trials in 
solid tumours. Clin Oncol (R Coll Radiol), 1997. 9(2): p. 100-14.
19.
Haffty, B.G., R. Hurley, and L.J. Peters, Radiation therapy with hyperbaric oxygen 
at 4 atmospheres pressure in the management of squamous cell carcinoma of the 
head and neck: results of a randomized clinical trial. Cancer J Sci Am, 1999. 5(6): 
p. 341-7.
20.
Kohshi, K., et al., Effects of radiotherapy after hyperbaric oxygenation on malignant 
gliomas. Br J Cancer, 1999. 80(1-2): p. 236-41.
21.
Overgaard, J., Hypoxic radiosensitization: adored and ignored. J Clin Oncol, 2007. 
25(26): p. 4066-74.
22.
Clarke, R.E., et al. Hyperbaric oxygen as a radiation sensitizer for locally advanced 
squamous cell carcinoma of the head and neck: A phase I dose-escalation study. 
in 2010 ASCO Annual Meeting. 2010. American Society of Clinical Oncology.

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Version: 10 – 17 March 2020
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23.
Banham, N.D., Oxygen toxicity seizures: 20 years' experience from a single 
hyperbaric unit. Diving Hyperb Med, 2011. 41(4): p. 202-10.
24.
Osoba, D., et al., The development and psychometric validation of a brain cancer 
quality-of-life questionnaire for use in combination with general cancer-specific 
questionnaires. Qual Life Res, 1996. 5(1): p. 139-50.
25.
Tariq, S.H., et al., Comparison of the Saint Louis University mental status 
examination and the mini-mental state examination for detecting dementia and 
mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry, 2006. 14(11): 
p. 900-10.
26.
Witham, T.F., et al., The characterization of tumor apoptosis after experimental 
radiosurgery. Stereotact Funct Neurosurg, 2005. 83(1): p. 17-24.
27.
Stein, D.M., et al., Use of serum biomarkers to predict cerebral hypoxia after 
severe traumatic brain injury. J Neurotrauma, 2012. 29(6): p. 1140-9.
28.
Shaw, E., et al., Single dose radiosurgical treatment of recurrent previously 
irradiated primary brain tumors and brain metastases: final report of RTOG 
protocol 90-05. Int J Radiat Oncol Biol Phys, 2000. 47(2): p. 291-8.
29.
Sperduto, C.M., et al., A validation study of a new prognostic index for patients 
with brain metastases: the Graded Prognostic Assessment. J Neurosurg, 2008. 
109 Suppl: p. 87-9.
30.
Sperduto, P.W., et al., Summary report on the graded prognostic assessment: an 
accurate and facile diagnosis-specific tool to estimate survival for patients with 
brain metastases. J Clin Oncol, 2012. 30(4): p. 419-25.
31.
Sperduto, P.W., et al., A new prognostic index and comparison to three other 
indices for patients with brain metastases: an analysis of 1,960 patients in the 
RTOG database. Int J Radiat Oncol Biol Phys, 2008. 70(2): p. 510-4.

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14 Attachments 
14.1 Table summarizing study procedures/flowchart
Visit 
sequence 
Type
Description
Data/Activities
#1
Initial 
consultation 
visit
Consults 
with 
radiation 
oncology and neurosurgery
H+P**
Protocol screening (check inclusion/exclusion 
criteria, including pathology/radiology)
Protocol consent
Bloodwork (CBC, CMP, pregnancy test if 
indicated)
Optional biomarker blood draw
Chest imaging if indicated (per section 3.1)
#2
Pre-treatment 
visit
HBO and SRS preparation
Patient familiarized with HBO technique (“dry 
run” through the HBO chamber)
RT-planning brain MRI
VisionRT open face mask fitting
CT-based simulation for SRS planning
#3
SRS 
treatment visit
HBO and SRS treatments
HBO 
SRS to brain metastases (beam-on goal within 
15 minutes after leaving HBO decompression)
#4+
Follow-up 
visit
Follow-up visits – 
the first  4-6 weeks after 
SRS, then every 3 months 
for two years, then every 4 
months for one year, then 
every 6 months for two 
years, then annually.
Individuals in the substudy 
for biomarkers will have an 
additional follow-up the day 
after the SRS treatment 
visit.
H+P**
Brain MRI
Bloodwork at first follow-up visit (CBC, CMP)
Optional biomarker blood draw
** Note:  All history/physical exam evaluations will include vital signs, performance status, 
neurological exam, mini-mental status exam, and QOL assessments (EORTC Quality of 
Life C-30 and BCM20).

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14.2 SAE Reporting Form
Please 
see 
SAE 
Reporting 
Form 
as 
detailed 
on 
the 
DHMC 
CPHS website:  http://www.dartmouth.edu/~cphs/tosubmit/forms/.  
14.3 HBO Treatment Protocol (including “dry run”)
HBO Protocol
14.3.1 
Prior to the first visit, any contraindications to hyperbaric treatment will be reviewed. 
Patients will be scheduled for a chest X-ray, if indicated.  
14.3.2
During the first visit patients will have a hyperbaric focused history and physical, and the 
results of any imaging tests will be reviewed.
Patients will then have a familiarization dive in the chamber. Prior to entering the chamber 
the patients will have an otoscopic exam. Patients will be placed in the chamber, and the 
chamber will be pressurized with air to 2.4 ATA. The pressure will then be released. After 
the patients come out of the chamber they will then have another otoscopic exam.
Patients who have difficulty with equalizing the pressure within their ears will be offered 
pressure-equalization tubes. 
14.3.3
On the treatment day, patients will come first to radiation oncology, where the procedure 
for the day will be reviewed. The patient will then return to hyperbarics to begin the 
hyperbaric treatment. 
The patients will remove jewelry, watches and any other items that are not approved for 
use in the chamber (e.g. electronics, matches, lighters, metal objects, cigarettes, car 
keys, coins/money, batteries, watches, shoes, hand warmers, newspapers, books, 
magazines, loose medications, stockings, hearing aids). They will remove their street 
clothes and put on 100% cotton gowns provided by the hyperbaric center. 
The chamber will be pressurized to 2.4 ATA at a compression rate (breathing oxygen) of 
approximately 1 – 3 psi per minute, depending on patient tolerance. The patient will 
receive hyperbaric oxygen for 30 minutes starting at the time the chamber reaches 2.4 
ATA. The decompression rate will be approximately 2-3 psig/fsw per minute depending 
on patient tolerance. When the treatment is finished, the patient will be removed from the 

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chamber and transported to the radiation oncology suite via stretcher while receiving 
100% non-rebreather face mask @ 15L/min to help maintain oxygen saturation.
The patient will have the Gill-Thomas-Cosman head frame or the VisionRT open face 
mask placed.  Pre-treatment imaging studies then will be performed on the radiation 
therapy treatment unit, to assure accurate localization of the planned treatment.  
Stereotactic radiosurgery treatment may then proceed.
The goal for time from leaving the hyperbaric chamber to “beam-on” in the radiation 
oncology suite is anticipated to be ≤ 15 minutes.
14.4 Quality of Life Instruments
14.4.1 St. Louis University Mental Status (SLUMS) exam

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14.4.2 EORTC QLQ C-30

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Used with permission.

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14.4.3 EORTC QLQ BN-20
Used with permission.

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14.5 Description of Biomarker Assays
Blood 
samples 
will 
be 
examined 
for 
cellular, 
secreted, 
and molecular 
biomarker expression levels.  Examples include:
14.5.1 S100 
S100 is a Ca++-binding protein that is found in astrocytes, oligodendrocytes, and 
Schwann cells. In Europe it is being used as a screening tool for traumatic brain injury in 
Emergency Departments, although this usage has not yet been approved by the FDA in 
the US.  It is thought to be a specific marker for neurological tissue injury. The ELISA test 
is commercially available.  Testing will be performed through agreement with DartLab 
resource.  One kit is estimated required per patient, which assumes serum storage 
(frozen at -70) of the first two patient samples until the third is collected in follow-up; 
therefore, serum storage will run about 4-6 weeks per patient.
14.5.2 Neuron-specific enolase (NSE)
NSE is a cytoplasmic glycolytic neuronal enzyme.  Like S100 it is relatively specific for 
neurological tissue injury. NSE may also be found elevated in patients with carcinoid 
tumors or neuroendocrine tumors such as small cell lung cancer.  Carcinoid tumors rarely 
metastasize to the brain and are excluded from this study.  Likewise, small cell lung 
cancer patients are excluded from this protocol.  ELISA test is commercially available.  
Testing will be performed through agreement with DartLab resource.  One kit is estimated 
required per patient, which assumes serum storage (frozen at -70) of the first two patient 
samples until the third is collected in follow-up; therefore, serum storage will run about 6 
weeks per patient.
14.6 Solicited Adverse Events
Nervous System Disorders 
Akathisia
Amnesia
Aphonia
Arachnoiditis
Ataxia
Central Nervous system necrosis
Cognitive disturbance
Concentration impairment
Depressed level of consciousness
Dizziness
Dysarthria

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Dysesthesia
Dysgeusia
Dysphasia
Encephalopathy
Facial muscle weakness
Headache
Hydrocephalus
Hypersomnia
Intracranial hemorrhage
Ischemia cerebrovascular
Leukoencephalopathy
Memory impairment
Meningismus
Neuralgia
Nystagmus
Paresthesia
Peripheral motor neuropathy
Peripheral sensory neuropathy
Presyncope
Seizure
Somnolence
Spasticity
Stroke
Syncope
Transient ischemic attacks
Tremor
Nervous system disorders – Other, specify
Cardiac Disorders 
Heart failure 
Gastrointestinal Disorders 
Toothache
Psychiatric Disorders 
Anxiety
Respiratory, Thoracic, and Mediastinal Disorders 
Pneumothorax
Sinus pain 
Ear and Labyrinth Disorders 
Ear and labyrinth disorders - Other, specify: Barotrauma 

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Eye Disorders 
Eye disorders - Other, specify