Intraoperative Pancreatic Cancer Detection Using Multimodality Molecular Imaging
Phase: PHASE2
Conditions: Pancreatic Adenocarcinoma
Sponsor: Eben Rosenthal

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Intraoperative Pancreatic Cancer Detection Using 
Multimodality Molecular Imaging 
Coordinating Study Center 
Stanford Cancer Institute 
875 Blake Wilbur Dr 
Stanford, CA 94305 
Protocol Director  
George Poultsides, MD 
Assistant Professor of Surgery 
Division of Surgical Oncology 
Department of Surgery 
875 Blake Wilbur Dr;  M/ 5641 
Phone:                            Fax:                      .   
Email:  gpoultsides@stanford.edu 
Co-Investigator 
Eben Rosenthal, MD 
Medical Director of the Cancer Center 
Professor of Surgery 
Department of Otolaryngology 
875 Blake Wilbur Dr;  CC-2213 
Phone:                            Fax:                      .   
Email:  elr@stanford.edu 
Co-Investigator 
Sanjiv Gambhir, MD, PhD 
Professor of Radiology 
Department of Radiology 
300 Pasteur Dr,  H2200 MC 5281 
Stanford, CA 94305 
Phone:                            Fax:                      .   
Email:  sgambhir@stanford.edu 
Co-Investigator 
George A Fisher, Jr, MD 
Colleen Hass Chair, School of Medicine 
Medicine – Oncology 
Stanford Cancer Center 
875 Blake Wilbur Dr;  MC 5826 
Stanford, CA  94305 
Phone:                            Fax:                      .   
georgeaf@stanford.edu 
Co-Investigator 
Sigurdis Haraldsdottir, MD 
Assistant Professor of Medicine – Oncology 
Stanford Cancer Center 
875 Blake Wilbur Dr;  MC 5826 
Stanford, CA  94305-5826  
sharalds@stanford.edu  
Visiting Scholar 
Willemieke Tummers, MD 
Depts of Surgical Oncology and Radiology 
James H Clark Center 
Stanford University 
Phone:                            Fax:                      .   
Email:  wtummers@stanford.edu 
NCT02736578 

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Chief of General Surgery 
Jeffrey Norton, MD 
Professor of Surgery 
Division of Surgical Oncology 
Department of Surgery 
875 Blake Wilbur Dr 
Phone:                                . 
Email:  janorton@stanford.edu 
Biostatistician 
George Poultsides, MD 
Assistant Professor of Surgery 
Division of Surgical Oncology 
Department of Surgery 
875 Blake Wilbur Dr;  M/ 5641 
Phone:                            Fax:                      .   
Email:  gpoultsides@stanford.edu 
Research Fellow 
Thuy Tran, MD 
Stanford University 
Department of Surgery, Div Surgical Oncology 
300 Pasteur Dr,  H3591 
Stanford, CA 94305 
Email:  trantb@stanford.edu 
Physician assistant, Surgical Oncology 
Kristan Wheeler 
Stanford Univ, Department of Surgery 
Division of Surgical Oncology 
300 Pasteur Dr;  H3591 
Stanford, CA 94305 
Email:  kwheeler@stanfordmed.org 
Post-Doctoral Researcher 
Raj Kothapalli, PhD 
Department of Radiology  
The James H Clark Center 
318 Campus Dr, Suite E-150 
Stanford, CA  94305 
Phone:                                . 
Email:  ksraj@stanford.edu  
Study Coordinator 
Alifia J Hasan 
Cancer Clinical Trials Office 
Stanford Univ, Medical Center 
800 Welch Rd,  FC3C74 
Palo Alto, CA, 94304 
Phone:                            Fax:                      .   
Email:  alifia@stanford.edu 
Collaborating Study Center 
(no subjects seen or treated) 
Investigator 
RJ Swijnenburg, MD, PhD 
Leiden University Medical Center 
Department of Surgical Oncology 
PO Box 9600, 2300 RC Leiden 
Phone:                            Fax:                      .   
E-mail:  r.j.swijnenburg@lumc.nl 
Investigator 
AL Vahrmeijer, MD, PhD 
Leiden University Medical Center 
Department of Surgical Oncology 
PO Box 9600, 2300 RC Leiden 
Phone:                            Fax:                      .   
E-mail:  a.l.vahrmeijer@lumc.nl 
IRB number:  IRB-35789  
IND number: IND-115706 (Eben Rosenthal, MD) 

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Document History 
Version Date 
Notes 
9 February 2016 
Submitted to IRB and IND 
5 April 2016 
 Added ECG assessment 30 minutes after the loading dose 
 Added the option of performing urine pregnancy test on the day of infusion if the serum 
pregnancy test is not within 72 hours 
11 April 2016 
Ex vivo tumor imaging process clarified 
20 July 2016 
Describes the use of the IR9000 cameras and the SurgVision Explorer Air.  Technical 
information for the SurgVision Explorer Air is provided in Appendix C.   
8 November 2016 
 Clarifies that subjects who experience a serious reaction will be discontinued (withdrawn), 
and will not count towards the study accrual target specified at 12.1 Statistical Design / 
Sample Size 
 Removes the optional requirement for Day 1 follow up 
 Specifies that certain AEs unrelated to the study drug may not be collected, as follows. 
o AEs that are solely laboratory values;  are not related to the study drug ;  AND are 
not clinically significant may not be collected. 
o Non-serious AEs that occur within 10 days after surgical resection of the tumor;  are 
not related to the study drug;  are not clinically significant;  AND are expected in the 
post-surgery clinical setting may not be collected.  
 
 

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TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ............................................................................................................. 6 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS .............................................. 9 
1. OBJECTIVES ...................................................................................................................... 10 
1.1. PRIMARY OBJECTIVES ...................................................................................................... 10 
1.2. SECONDARY OBJECTIVES ................................................................................................. 10 
2. BACKGROUND .................................................................................................................. 10 
2.1 STUDY DISEASE ................................................................................................................ 10 
2.2 STUDY AGENT/DEVICE/PROCEDURE ................................................................................. 14 
2.3 RATIONALE ....................................................................................................................... 14 
2.4 STUDY DESIGN ................................................................................................................. 15 
3.1 INCLUSION CRITERIA ........................................................................................................ 20 
3.2 EXCLUSION CRITERIA ....................................................................................................... 20 
3.3 INFORMED CONSENT PROCESS .......................................................................................... 20 
3.4 REGISTRATION PROCESS ................................................................................................... 21 
3.5 STUDY TIMELINE .............................................................................................................. 21 
4. TREATMENT PLAN .......................................................................................................... 21 
4.1 TREATMENT SCHEDULE .................................................................................................... 21 
4.2 ADMINISTRATION OF CETUXIMAB-IRDYE800 ................................................................... 22 
4.3 DEFINITION OF DOSE-LIMITING TOXICITY (DLT) AND COHORT EXPANSION .................... 22 
4.4 SURGICAL IMAGING .......................................................................................................... 23 
4.5 GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES .................. 23 
4.6 CRITERIA FOR REMOVAL FROM STUDY ............................................................................. 23 
5. INVESTIGATIONAL AGENT INFORMATION ........................................................... 24 
5.1 DESCRIPTION OF STUDY DRUG ......................................................................................... 24 
5.2 EXPECTED TOXICITIES ...................................................................................................... 27 
5.2.1 
Infusion Reaction .................................................................................................................................................. 27 
5.2.2 
Allergic Response .................................................................................................................................................. 27 
5.2.3 
Cardiac Toxicity ..................................................................................................................................................... 27 
5.2.4 
Pulmonary Toxicity .............................................................................................................................................. 28 
5.2.5 
Dermatologic Toxicity ........................................................................................................................................ 28 
5.2.6 
Hypomagnesemia and Electrolyte Abnormalities ................................................................................. 28 
5.2.7 
Other Toxicities ...................................................................................................................................................... 28 
5.3 STUDY DRUG DISCONTINUATION ...................................................................................... 29 
5.4 AVAILABILITY .................................................................................................................. 29 
5.5 AGENT ORDERING ............................................................................................................ 29 
5.6 AGENT ACCOUNTABILITY ................................................................................................. 29 
6. DOSE MODIFICATIONS .................................................................................................. 29 
7. ADVERSE EVENTS AND REPORTING PROCEDURES ............................................ 30 
7.1 ADVERSE EVENT ............................................................................................................... 30 
7.2 SERIOUS ADVERSE EVENT ................................................................................................ 30 
7.3 ASSESSMENT OF CAUSALITY............................................................................................. 30 
7.4 SEVERITY OF ADVERSE EVENTS ....................................................................................... 31 

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7.5 SAFETY MONITORING AND REPORTING ............................................................................ 31 
8. CORRELATIVE/SPECIAL STUDIES ............................................................................. 32 
9. STUDY CALENDAR .......................................................................................................... 33 
10. MEASUREMENTS ............................................................................................................. 37 
10.1  PRIMARY OUTCOME MEASURE ...................................................................................... 37 
10.2  SECONDARY OUTCOME MEASURE ................................................................................. 37 
11. MULTISITE REGULATORY CONSIDERATIONS ..................................................... 37 
11.1 MONITORING PLAN ......................................................................................................... 37 
11.2 ROLE OF THE STANFORD DATA AND SAFETY MONITORING COMMITTEE (DSMC) ......... 38 
11.3 PROTOCOL REVIEW AND AMENDMENTS ......................................................................... 38 
11.4 DATA MANAGEMENT ...................................................................................................... 38 
11.5 STUDY DOCUMENTATION ............................................................................................... 38 
12. STATISTICAL CONSIDERATIONS ............................................................................... 39 
12.1 STATISTICAL DESIGN ...................................................................................................... 39 
13. REFERENCES .................................................................................................................... 41 
APPENDICES ............................................................................................................................. 45 
APPENDIX A:  PARTICIPANT ELIGIBILITY CHECKLIST ............................................................ 45 
APPENDIX B: IR9000 FLUORESCENCE IMAGING SYSTEM, NOVADAQ. ................................... 48 
APPENDIX C: EXPLORER AIR, SURGVISION ............................................................................ 49 
APPENDIX D: PHOTOACOUSTIC IMAGING ............................................................................... 52 

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PROTOCOL SYNOPSIS 
 
TITLE 
Intraoperative Pancreatic Cancer Detection Using Multimodality 
Molecular Imaging 
STUDY PHASE 
Phase 1-2 
INDICATION 
Clinically suspected or biopsy proven diagnosis of pancreatic 
cancer.  Subjects diagnosed at any T stage who are scheduled to 
undergo surgical resection as part of standard of care are eligible.  
INVESTIGATIONAL 
PRODUCT  
A Cetuximab-IRDye800 dose of either 50 mg or 100 mg will be 
injected 2 to 5 days before surgery.  No more than one subject 
will receive the investigational agent on the same day. 
TREATMENT 
SCHEDULE  
Subjects will undergo surgical resection 2 to 5 days after infusion 
of Cetuximab-IRDye800.  Intraoperative imaging will be 
performed using the intraoperative optical imaging devices 
Novadaq SPY/LUNA;  Novadaq IR9000 Fluorescence Imaging 
System with Open-Field Handheld Fluorescence Imaging Camera 
and/or Pinpoint Endoscopic Fluorescence Imaging Camera;  and 
SurgVision Explorer Air multi-spectral fluorescence reflectance 
system.  Ex vivo, non-invasive imaging of the specimen prior to 
pathological assessment will be performed using investigational 
optical and photoacoustic imaging devices without violation of 
the tissue.  
Cetuximab-IRDye800 Dosing Schedule 
Cohort 
Dose of 
Cetuximab-IRDye800 
Dose of  
Unlabeled Cetuximab 
prior to infusion of 
Cetuximab-IRDye800 
1 
50 mg 
100 mg 
2 
100 mg 
100 mg 
 
 
PRIMARY 
OBJECTIVE(S) 
To determine the efficacy of Cetuximab-IRDye800 in identifying 
pancreatic cancer compared to surrounding normal tissue as 
measured by tumor to background ratio. 
SECONDARY 
OBJECTIVE(S) 
To determine the tolerability of the Cetuximab-IRDye800 
imaging agent in pancreatic cancer subjects 

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SAMPLE SIZE AND 
STUDY DURATION 
It is anticipated that 10 subjects will be enrolled into the study 
(5 in each cohort).  Each subject will be followed for 30 days 
following the last dose of study medication.  Based on the 
enrollment rate for the current head and neck cancer 
Cetuximab-IRDye800 trial, it is anticipated that the study will 
require 12 to 18 months to be completed.  
STATISTICAL 
CONSIDERATIONS 
The primary objective is to correlate fluorescence with 
histological evidence of tumor relative to background tissue.  The 
gross and histological properties of the primary tumor will be 
correlated with the fluorescence intensity as measured in the 
operating room using the intraoperative optical imaging devices 
Novadaq SPY/LUNA;  Novadaq IR9000 Fluorescence Imaging 
System with Open-Field Handheld Fluorescence Imaging Camera 
and/or Pinpoint Endoscopic Fluorescence Imaging Camera;  and 
SurgVision Explorer Air multi-spectral fluorescence reflectance 
system.  A board certified pathologist will perform pathological 
confirmation of tumor, which will serve as the gold standard.  In 
pathology, the tumor will processed using standard of care for the 
purposes of patient care, these tissues or any waste tissues from 
the subject will be made available for optical imaging using 
several optical and photoacoustic imaging devices.  The linear 
relationship between fluorescence and tumor weight will be 
computed as Spearman’s correlation coefficient.  The bias present 
between the measurements will be expressed in relationship to 
the tumor volume and fluorescence expressed as the mean 
difference with a 95% confidence interval.  Continuous variable 
means (eg, fluorescence intensity) will be compared to 
histological quantification of tumor as previously noted and 
previously performed by us (Kulbersh, et al, 2007;  Rosenthal, 
Kulbersh, King, Chaudhuri,  Zinn, 2007;  Rosenthal, et al, 2015).  
The sensitivity and specificity of these experiments will be 
determined based on histological confirmation of tumor within 
the margin specimens, as performed previously by us in 
preclinical models (Kulbersh, et al, 2007;  Withrow, et al, 2007;  
Withrow, et al, 2008).  Animal models demonstrate a sensitivity 
of 92% and specificity of 100% using fluorescently labeled 
Cetuximab (Kulbersh, et al, 2007).  Frozen sections obtained 
from subjects per the standard of care will be analyzed for 
fluorescence intensity and the presence of tumor will be 
confirmed by histology.  
The secondary objective will be measured as the occurrence of a 
Dose-limiting Toxicity (DLT) event, defined as any Grade 2 or 
greater toxicity that is considered possibly or definitely related to 
the study drug, is considered clinically significant by the 
investigator and occurs within 15 days of receiving treatment.  

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Subjects will be monitored using standard clinical parameters to 
evaluate for toxicity.  Subjects will be observed immediately after 
infusion of the unlabeled test/loading dose for an infusion 
reaction to Cetuximab.  If there is no serious reaction, the subject 
will be enrolled in the study and receive the study drug.  Subjects 
who experience a serious reaction will be discontinued 
(withdrawn), and will not count towards the study accrual target 
specified at 12.1 Statistical Design / Sample Size.  The following 
observations and tests shall be performed after treatment to 
identify both acute and late treatment specific toxicity:  physical 
exam, toxicity grading, assignment of performance status, and at 
certain intervals blood chemistries (complete metabolic profile to 
include magnesium and phosphorus).  NCI Common Toxicity 
Criteria v 4.0 will be used for grading of toxicity.  Safety 
endpoints are type, incidence, severity, seriousness, and study 
treatment relatedness.  Descriptive statistical analysis of subject 
disposition, baseline characteristics, exposure to study drug, and 
adverse events (AEs) will be performed.  Descriptive statistics for 
continuous data will include mean, standard deviation, median, 
minimum, and maximum values.  Frequencies and percentages 
will be used to summarize categorical data. 
 

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS  
 
AE 
Adverse Event 
BID 
Twice Daily 
BSA 
Body Surface Area 
CBC 
Complete Blood Count 
CI 
Confidence Interval 
CMAX 
Maximum Concentration Of Drug 
CNS 
Central Nervous System 
CRF 
Case Report/Record Form 
CTCAE 
Common Terminology Criteria For Adverse Events 
DLT 
Dose-Limiting Toxicity 
DSMC 
Data Safety Monitoring Committee 
ECG 
Electrocardiogram 
ECOG 
The Eastern Cooperative Oncology Group 
EGFR 
Epidermal Growth Factor Receptor 
FDA 
Food and Drug Administration 
GI 
Gastrointestinal 
GMP 
Good Manufacturing Practice 
Hgb 
Hemoglobin 
HNSCC 
Head And Neck Squamous Cell Carcinoma 
HTN 
Hypertensions 
ICG 
Indocyanine green 
ILD 
Interstitial Lung Disease 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IV 
Intravenous 
LLN 
Lower Limit Of Normal  
MTD 
Maximum Tolerated Dose 
NIR 
Near Infra-Red 
NHS 
N-hydroxysuccinimide 
PAI 
Photoacoustic imaging 
PDAC 
Pancreatic ductal adenocarcinoma 
PLT 
Platelet 
ROI 
Regions of Interest 
SAE 
Serious Adverse Event 
SCC 
Squamous Cell Carcinoma 
SNR 
Signal to Noise Ratio 
TBR 
Tumor to Background Ratio 
ULN 
Upper Limit Of Normal 
UNK 
Unknown 
WBC 
White Blood Cell 
WHO 
World Health Organization 

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1. 
OBJECTIVES 
1.1. 
Primary Objectives  
The primary objective of the study is to determine the efficacy of Cetuximab-IRDye800 in 
intraoperatively identifying pancreatic cancer compared to surrounding normal pancreatic and 
extrapancreatic tissue, as measured by tumor-to-background ratio. 
1.2. 
Secondary Objectives 
 
The secondary objective is to determine the tolerability of the Cetuximab-IRDye800 as an 
imaging agent in subjects undergoing resection of pancreatic cancer. 
2. 
BACKGROUND 
Need for optical imaging to guide surgical resection of pancreatic cancer.  There is currently 
no pancreatic cancer specific contrast agent available for preoperative and/or intraoperative 
imaging.  Despite significant investment in systemic therapy for small incremental gains in 
survival, there has been minimal investment in improving surgical outcomes despite the 
overwhelming number of patients who undergo surgical resection for pancreatic cancer every 
day in the United States. 
We propose to leverage previous investment in systemic therapy to improve the completeness of 
surgical resection and improve the margin positivity rate, which can be as high as 85% in certain 
series with standardized pathological processing (Chang, et al, 2009;  Esposito, et al, 2008;  
Kooby, et al, 2014;  Van den Broeck, et al, 2009;  Verbeke and Gladhaug, 2012;  
Wagner, et al, 2004;  Winter, et al, 2006).  This study would demonstrate important proof of 
principle and translate concepts that molecular biologists have used for more than a decade to 
identify and label cancer in real-time.  Successful completion of this study would have a lasting 
impact on the field of surgical oncology. 
2.1 
Study Disease 
Importance of Margin Clearance in Pancreatic Cancer.  Pancreatic cancer is the fourth 
leading cause of cancer death in the Western world, with 5-year survival rate of less than 5% 
(Jemal, et al, 2010).  At diagnosis, 75 to 85% of patients are not eligible for resection, due to 
early locoregional and/or distant spread (Barugola, et al, 2009).  Two major predictors of 
long-term survival are the ability to resect the tumor with cancer-free resection margins and the 
absence of systemic metastases.  However, margin-positive resections are a frequent 
phenomenon (Verbeke, Gladhaug, 2012) as is the emergence of distant metastases soon after 
surgery (which were likely present at the time of surgery in the form of non-detectable 
micrometastases).  These factors create significant challenges for the proper selection of patients 
for surgery, as well as for decision-making during the actual procedure in order to achieve 
complete clearance of the tumor or abort a non-curative resection.  

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Pancreatic cancer can be difficult to visualize intraoperatively.  Non-curative resection has 
been a significant limitation in the management of pancreatic cancer given the lack of 
intraoperative tools to discriminate between benign/inflammatory pancreatic parenchyma versus 
pancreatic cancer tissue.  This limitation results in: 
1. Incomplete resection of tumors, which could have been resected completely 
2. Incomplete resection of tumors that could have been identified at operation as 
unresectable if the local extent of tumor growth were assessable. 
3. Incomplete lymph node clearance due to lack of knowledge of involved or potentially 
involved lymph nodes. 
4. Resection of pancreatic tumors in the presence of visually or radiographically occult 
systemic metastasis (liver or peritoneum). 
In these situations, patients undergo operations with reduced oncologic benefit, but with a high 
risk of deterioration of quality of life due to a major operation at an end stage of life.  The use of 
high-targeted molecular imaging has the potential to provide crucial information to surgeon in 
the above-described situations, both in the form of photoacoustic imaging, which can provide 
intraoperative ultrasound images at clinically relevant depths (5 to 7 cm) with high special 
resolution (Zackrisson, van de Ven, Gambhir, 2014), and in the form of fluorescent optical 
imaging, which on the other hand is superior for imaging superficial lesions (Vahrmeijer, 
Hutteman, van der Vorst, van de Velde,  Frangioni, 2013). 
Intraoperative frozen sections are used to confirm complete resection of tumors.  Frozen 
section analysis of specimen margins has significant deficiencies, as it 1) requires resection of 
additional tissue for assessment;  2) adds between 30 and 60 minutes to the operative time;  3) is 
difficult to interpret in patients with other pancreatic diseases or previous irradiation;  4) cannot 
be performed on fat;  5) is reversed on permanent section in approximately 5% of cases and 6) 
fails to detect close margins (< 5 mm) (DiNardo, Lin, Karageorge, Powers, 2000).  Finally and 
perhaps most importantly, frozen sections are highly accurate if the right tissue is biopsied and 
sent, however, less than 5% of the resection bed can be assessed by frozen section and this 
significantly limits the sensitivity of this technique.  This sampling error consistently plagues 
surgeons and pathologists alike.  
Current intraoperative hardware can successfully image the Cetuximab-IRDye800 in vivo.  
Novadaq currently manufactures an FDA-approved intraoperative device for imaging 
intravascular flow of indocyanine green in plastic surgery procedures.  These systems include the 
SPY or LUNA system, the PINPOINT device for laparoscopic imaging, and the FIREFLY for 
robotic assisted imaging.  Although not specifically designed to image Cetuximab-IRDye800, 
the emission and absorption spectrum of these two optical agents (indocyanine green and 
IRDye800) have significant overlap and we present data to show that this system can 
successfully detect microscopic disease in preclinical models (Heath, Deep, Sweeny, Zinn, 
Rosenthal).  Development and manufacturing of new hardware for the purpose of specifically 
imaging Cetuximab-IRDye800 is currently done by Novadaq, creating the IR9000 Fluorescence 
Imaging System.  However, no clinical study is yet done with that device.  Similar technologies 
are being incorporated into minimally invasive technologies, which are ideally suited to optical 
imaging.  
Will tissue penetration be sufficient to identify cancer?  Indocyanine green is a fluorescent 
dye with very similar properties to IRDye800 that is routinely used in humans to evaluate 

IRB-35789 
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vascular flow in the surgical setting with strong penetration through skin and other structures 
(Yamamoto, et al.).  Furthermore, indocyanine green has been successfully administered at 
microdosing levels to study lymphatic drainage in humans (Rasmussen, Tan, Marshall, Fife, 
Sevick-Muraca, 2009;  Sharma, et al, 2008).  Unfortunately, indocyanine green does not have a 
function group for conjugation to other proteins.  However, IRDye800 is a stable near infrared 
imaging dye that can be conjugated to antibodies without significant alteration of ligand binding.  
We chose this dye because it is the only optical dye we are aware of that has undergone safety 
testing and is being evaluated by the FDA for use in humans.  
Improved visualization would significantly improve minimally invasive surgical techniques.  
Optical imaging is ideally suited to endoscopic and laparoscopic/robotic operative approaches 
since the surgeon is looking directly at the video monitor and fluorescence can be easily 
incorporated into the surgeons view.  Furthermore, most current versions of intraoperative 
microscopy recognize the importance of future applications of fluorescence and have developed 
systems to image at a wavelength that could easily accommodate Cetuximab-IRDye800, such as 
the OH5 FL800 (Leica Microsystems) and Pentero 900 (Carl Zeiss) microscopes. 
EGFR is highly expressed in pancreatic ductal adenocarcinoma (PDAC) and is a good 
target for fluorescence imaging, due to its transmembrane position.  Cancer-specific surgical 
navigation has been successfully introduced for certain cancer types and it requires accurate 
localization of vector molecules to cancer cells.  In the past, studies demonstrated image-guided 
pancreatic surgery using, the non-tumor specific near-infrared dye, indocyanine green.  They 
showed that no useful tumor demarcation could be visualized in pancreatic cancer patients, most 
likely due to the non-specific character of the dye (Hutteman, et al, 2011).  This clearly 
delineates the importance of using a tumor-specific imaging agent for pancreatic cancer, to 
improve patient outcomes by enhancing accurate staging, and more effective, tumor-margin free 
pancreatic resection.  However, to date no clinical studies with tumor-specific imaging agents for 
pancreatic cancer have been performed. 
Studies have shown EGFR overexpression in pancreatic cancer to range from 30-95% 
(Bloomston, Bhardwaj, Ellison, Frankel, 2006;  Uegaki, et al, 1997).  And certain 
EGFR-directed therapies are currently FDA approved for pancreatic cancer treatment, such as 
erlotinib (Kelley, Ko, 2008;  Philip, Lutz, 2015).  Preliminary studies from our research group 
showed that epidermal growth factor receptor (EGFR) is a promising target for pancreatic 
cancer.  In a cohort of 129 patients with different stages of PDAC, EGFR was abundantly 
expressed in up to 70% of pancreatic cancer samples (de Geus, et al.  Manuscript in 
preparation).  To validate these results, we also tested the markers on tissues of patients with 
chronic pancreatitis and in lymph node metastases.  These experiments confirmed that EGFR is 
an appropriate tumor-specific marker, also able to differentiate between benign and malignant 
pancreatic lesions, which is crucial in pancreatic surgery (Tummers, et al.  Manuscript in 
preparation). 
In addition, research efforts continue to elucidate a possible role for cetuximab in the treatment 
of pancreatic cancer.  Cetuximab has shown anti-tumor activity either alone or in combination 
with other agents and is currently FDA approved for use in both head and neck squamous cell 
carcinoma (HNSCC) and colorectal carcinoma.  Other studies have established the safety profile 
of Cetuximab in pancreatic cancer patients (Arnoletti, et al, 2011;  Ho, et al, 2011).  

IRB-35789 
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Our group has shown that EGFR based optical imaging can detect subclinical disease 
(non-palpable tumor) within the resection bed approximately 72 hours after systemic 
administration of the fluorescently labeled anti-EGFR antibody (Day, Beck, Heath, et al, 2013;  
Day, Sweeny, Kulbersh, Zinn, Rosenthal, 2013).  The potential of optical imaging to guide 
surgical resection by capitalizing on the overexpression of EGFR has also been supported by the 
findings of other groups in a variety of solid tumors (Agnes, et al, 2012;  Kobayashi, et al, 2012;  
Qi, et al, 2012;  Yang, et al, 2013).  
 
Do tumors need to express high levels of EGFR for successful fluorescence imaging?  Early 
data from clinical trials evaluating the relationship between fluorescence intensity and EGFR has 
suggested that 1) Mean Fluorescence Intensity (MFI) correlates with the expression of EGFR 
and 2) even very low levels of EGFR expression are sufficient for strong fluorescent signal 
(Figure 1).  Analysis of human tissues after systemic injection of Cetuximab-IRDye800 in head 
and neck cancer patients revealed that EGFR expression correlated with mean fluorescence 
intensity (MFI).  Clearly, Cetuximab-IRDye800CW uptake within SCC was specifically 
localized to areas that expressed EGFR.  The univariate association between EGFR density and 
MFI was observed at all three dosing cohorts (P < 0.001, Figure 1b).  A 6-fold increase in MFI 
was seen at the two higher doses compared to the lower dose concentration (P<0.001);  no 
Figure 1.  Co-localization of 
fluorescence signals of 
Cetuximab-IRDye800CW 
and Epidermal Growth 
Factor Receptor (EGFR) 
expression.  
(a) Representative 
haemotoxylin/eosin (H&E) 
image indicating tumor (T) 
and normal (N) with 
corresponding EGFR 
expression 
immunohistochemistry stain 
and fluorescence image.  
(b) Increase in Mean 
Fluorescence Intensity (MFI) 
as a function of EGFR 
Density (% area EGFR 
positive).  Data are presented 
as mean±SD, * = P<0,001.  
Scale bars in all images 
represent 100μm.  

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9 August 2016 
significant increase in MFI was seen when comparing the highest dose (62.5 mg/m2) with the 
middle dose 25 mg/m2.  (P > 0.05).  
2.2 
Study Agent/Device/Procedure 
Cetuximab-IRDye800 is produced by mixing the two components in phosphate buffer at pH 8.5 
and allowing the reaction to proceed at 20 to 25ºC.  The conjugation reaction is followed by a 
buffer exchange into pH 7.4 PBS.  The desired stoichiometry for the product is approximately 
1.5 dye molecules per antibody molecule.  Cetuximab-IRDye800 has been produced under 
cGMP conditions at University of Alabama at Birmingham using cGMP IRDye800CW and 
commercially available cetuximab.  Formal testing of the Cetuximab-IRDye800 for stability, 
sterility and antigen specificity is contained within the CMC section according to an 
FDA-approved process.  The manufacturing and quality processes are documented elsewhere. 
Cetuximab-IRDye800 has recently been used for the first time in humans, in head and neck 
cancer patients.  Comparing cetuximab with Cetuximab-IRDye800 identified very limited 
differences between the 2 agents, however there are several relevant findings: 
1) The study demonstrated that the pharmacokinetics of single dosing with 
Cetuximab-IRDye800 are very similar to cetuximab;  both have half-life of 2.6 days 
when dosed at 250 mg/m2.  Therefore data will be collected using the known 
pharmacokinetics of cetuximab.  
2) A small but statistically significant increase in the QTc interval was identified during the 
infusion of cetuximab or Cetuximab-IRDye800.  Therefore patients at risk for 
arrhythmias associated with QT prolongation will be excluded (see exclusion criteria). 
For clinicaltrials.gov compliance 
The investigational agent for this study, Cetuximab-IRDye800, is not approved by the FDA, and 
an Investigational New Drug application (IND) is required for this study.  (Note:  The antibody 
moiety of the investigational agent is approved by FDA as Erbitux (cetuximab).  
The IND for this study is IND-115706.  
2.3 
Rationale 
Overall Impact of Proposed Studies on Surgical Oncology.  Introduction of this technology to 
the operating room in the manner we propose would represent a paradigm shift in oncologic 
surgery.  Current methods for detecting surgical margins are subjective (surgeon’s inspection and 
palpation) and time consuming (frozen section analysis).  The use of optical imaging would be a 
significant improvement in real-time identification of cancer – when the surgeon can act on the 
information and extend the resection to achieve negative margins.  The development of a cancer 
specific contrast agent of this type can be applied to other solid tumors that express EGFR.  
Furthermore, if the principle of targeted optical imaging is validated using EGFR, other 
therapeutic antibodies could be assessed for imaging potential. 
Proposed studies will dramatically improve current standard of care in following ways: 
1) Detect subclinical disease in the operating room at the time of resection:  Our preclinical 
data suggests tumor volumes of greater than 450 cells are detectable by this technique 
(Rosenthal, Kulbersh et al.  2006, Rosenthal, Kulbersh et al.  2007).  

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2) Real time feedback:  Tumor margins and then residual disease can be assessed 
intraoperatively.  
3) Improve minimally invasive techniques:  Use of endoscopes in body cavities with limited 
light represents ideal conditions for this technology. 
4) Use in other cancer types:  EGFR is highly-expressed in multiple cancer types, allowing 
application to other tumor types beyond pancreatic cancer and HNSCC.  
5) Potential other clinical applications:  Cancer detection by laparo-endoscopic techniques 
during screening or post-treatment surveillance(Gleysteen, Duncan, et al, 2007b).  
6) High feasibility.  We have previously conducted toxicity studies in non-human primates 
(Zinn, et al, 2015) and in a dose escalation phase 1 clinical trial using Cetuximab-IRDye800 
in head and neck cancer patients (Rosenthal, et al, 2015).  
2.4 
Study Design 
For clinicaltrials.gov and Stanford Clinical Trials Directory compliance: 
 The primary purpose for the protocol is Image Guidance.  This study evaluates if 
Cetuximab-IRDye800, a dye conjugate intended to identify cancer compared to 
surrounding normal tissue, improves intraoperative identification of pancreatic cancer vs 
surrounding normal pancreatic and extrapancreatic tissue, as measured by 
tumor-to-background ratio.  
 There are 2 cohorts. 
 The study is Open-label.  No masking is used.  
 The study is non-randomized.  
 The primary outcome is Efficacy.  
The study is an open-label study to determine the efficacy and safety profile of conjugated 
Cetuximab-IRDye800 used in subjects with pancreatic cancer that undergo surgery.  This study 
aims to evaluate the specificity of cetuximab conjugated to the fluorescent dye (IRDye800CW) 
in the intraoperative detection of micrometastatic disease in the peritumoral lymph nodes, 
primary tumor, and other distant sites.  
Previous data in nonhuman primates (n = 8) and in humans (n = 15) suggest that 
Cetuximab-IRDye800 behaves similarly to unlabeled cetuximab, but its efficacy and safety 
remains largely unknown because of the limited clinical experience (Rosenthal, et al, 2015;  
Zinn, et al, 2015).  The manufacturing places 1 or 2 dye molecules per antibody, which is 
theorized to have minimal impact on the pharmacodynamics and toxicity of the antibody-dye 
compared to the antibody alone.  These studies have suggested that the risk of 
Cetuximab-IRDye800 at this sub-therapeutic dose is similar but not equivalent to the toxicity of 
cetuximab.  
A total of 10 subjects will be enrolled in the proposed study.  During and after 
Cetuximab-IRDye800 infusion, allergic reactions will be monitored and safety measurements 
will be taken, such as hemodynamic monitoring, EKG, blood tests, and physical examination.  If 
three or more participants of the study experience dose limiting toxicity (DLT), then the study 
will be stopped and the data reviewed.  Dose limiting toxicity (DLT) will be defined as any 
Grade 2 or greater toxicity that is considered possible, probably or definitely related to the study 
drug and considered clinically significant by the investigator, and occurs within 7 days of 

IRB-35789 
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receiving treatment, which represents more than 4 half-lives of the drug.  Restarting will require 
reassessment after discussion and approval by the medical monitoring board.  
We will administer a test/loading dose of unlabeled cetuximab (no dilution required) over 
30 minutes via IV and observe for 30 minutes.  The administration of this dose of unlabeled 
cetuximab has two purposes:  1) a test dose will allow toxicity related to cetuximab alone to be 
differentiated from hypersensitivity reactions associated with Cetuximab-IRDye800, and 
2) Because the liver acts as an EGFR ‘sink,’ a loading dose of cetuximab is given as standard of 
care in therapeutic delivery of the drug.  Because of this, we have proposed the use of a 100 mg 
pre-treatment dose to saturate some of the liver receptors prior to administration of 
Cetuximab-IRDye800.  Tumor saturation with the test dose is unlikely based on our preclinical 
studies of tumor cells in vitro (Helman, et al.) and in vivo (Gleysteen, et al, 2007).  Our 
preclinical studies with excess unlabeled anti-EGFR support this conclusion as tumor retention 
of fluorescent-anti-EGFR antibody was still imaged under these conditions 
(Gleysteen, et al, 2007). 
Subjects will be assigned in 2 cohorts.  Cohort 1 will receive by IV infusion a 100 mg unlabeled 
test/loading dose of cetuximab and 50 mg of Cetuximab-IRye800.  Cohort 2 will receive by 
IV infusion a 100 mg unlabeled test/loading dose of cetuximab and 100 mg of 
Cetuximab-IRDye800.  The rationale for these doses are based on preliminary results for our 
phase 1 clinical trial (Rosenthal, et al, 2015) which demonstrated 1) 50 mg dose provides the 
highest tumor-to-background ratio compared to other doses;  2) 100 mg dose is within the range 
of head and neck cancer trial and is based on the difference between the tumor types, looking at 
anatomical localization, the need for detection of micrometastases, and positive lymph nodes;  
and 3) the 100 mg unlabeled test/loading dose is optimal in reducing normal tumor background.   
Cohort 
Number of 
Subjects 
Dose Cetuximab-
IRDye800 
Loading Dose 
unlabeled cetuximab 
Time between 
infusion and surgery 
1 
5 
50 mg 
100 mg 
2 to 5 days 
2 
5 
100 mg 
100 mg 
2 to 5 days 
Pharmacokinetic Intervals.  Because the pharmacokinetics of single dose cetuximab are well 
known and the pharmacokinetics of cetuximab and Cetuximab-IRDye800 were nearly the same 
in non-human primate studies (see toxicology section), only limited pharmacokinetics will be 
performed (Tan, et al, 2006).   Blood levels will be monitored before infusion (up to 30 days 
before), after infusion (2 h), on Day 1 as available, on Day 2 to 10, and on Day 15 to 30 for 
Cetuximab-IRDye800 and free IRDye800.  Clearance of cetuximab occurs through the binding 
in the liver and through the reticuloendothelial system as occurs with endogenous 
immunoglobulin. 
Subjects will undergo surgical resection 2 to 5 days after infusion of Cetuximab-IRDye800.  
Initial estimates of timing of surgery were based on preclinical findings which show peak 
imaging time approximately 3-5 after injection which allows time for the antibody to accumulate 
within the tumor (Day, Beck, Deep, et al, 2013;  Day, Beck, Heath, et al, 2013;  Day, 
Sweeny, et al, 2013;  Heath, Deep, Sweeny, Zinn, Rosenthal, 2012) and later confirmed by 
human studies (data not shown).  Intraoperatively, tumor imaging will be performed in vivo to 
assess optimal tumor-to-background ratio (TBR).  TBR is defined as fluorescent signal of tissue 

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compared to florescent signal of tissue surrounding the tumor at different doses.  The number 
and location of detected lesions by conventional and optical techniques will be recorded on a 
schematic case-report form (CRF).  After surgery, non-invasive investigational optical and 
photoacoustic imaging modalities will be used without violation of the tissue.  With these 
modalities both TBR and the signal-to-noise ratio measured in dB (SNR) of the tumor will be 
calculated in the region of interest (ROI) and compared to normal surrounding tissue.  This will 
be done to determine if those imaging techniques are complementary to each other and thereby 
an advantage for pancreatic cancer surgery.  In addition, routine hematoxylin and eosin (H&E) 
staining will be done for histologic assessment and correlated with optical imaging.  
Immunohistochemistry on unstained tissue sections of the tumor and normal tissue will be 
performed as well as evaluate EGFR-expression.  The standard of care will not be violated 
during the surgical management or the pathological processing of tissues. 
Subjects will be monitored using standard clinical parameters to evaluate for toxicity.  Subjects 
will be observed immediately after infusion of the unlabeled test/loading dose for an infusion 
reaction to cetuximab.  If there is no serious reaction and the subject receives the full test dose of 
unlabeled cetuximab, the subject will continue on-study and receive the study drug 
Cetuximab-IRDye800.  The following observations and tests shall be performed after treatment 
to identify both acute and late treatment-specific toxicity:  physical exam;  toxicity grading;  
ECG;  assignment of performance status;  and at certain intervals blood chemistries (complete 
metabolic profile to include magnesium and phosphorus).  NCI Common Toxicity Criteria v4.0 
will be used for grading of toxicity.  
Imaging.  Imaging will occur intra-operatively and during pathological processing (see Figure 2 
below).  
 
Optical and photoacoustic imaging systems 
Ex vivo photoacoustic 
detection of specimens 
SPY/LUNA, IR9000 
Fluorescence Imaging 
Systems and Explorer Air 
for imaging in the 
operating room 

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Figure 2.  Schematic of intraoperative and pathological imaging of cancer to assess surgical margins.  
Anti-EGFR antibody conjugated to IRDye800 was injected systemically into an immunodeficient mouse 
bearing a xenografted squamous cell carcinoma and imaged after 48 hours. 
In Vivo Fluorescent Imaging.  An optical imaging system (approved optical device or IRB 
approved device) will be used to image the tumor in the operating room.  These devices are FDA 
approved for measuring intraoperative blood flow after indocyanine green (ICG) injection.  
Because IRDye800 and ICG have overlapping excitation and emission spectra, the SPY/LUNA 
System and PINPOINT based IR9000 Fluorescence Imaging System, Novadaq, can be used for 
imaging subclinical disease based on our preclinical studies in head and neck cancer 
(Heath, et al).  The IR9000 Fluorescence Imaging System, Novadaq, is based on the Novadaq’s 
commercial PINPOINT Endoscopic Fluorescence Imaging System (PC9000), see Appendix B.  
Intraoperative imaging is performed with the camera head approximately 6 to 12 inches from the 
tumor using variable integration timing.  When imaging the tumor in situ we propose to calculate 
tumor to background ratio (TBR).  The fluorescence intensity of the tumor is compared to the 
grossly normal tissue imaged within the field and provides an assessment of 
Cetuximab-IRDye800 uptake within the tumor compared to normal tissues.  Multiple 
measurements can be obtained at the time of surgery from a still images and histograms for 
regions generated using ImageJ (NIH) as we have previously described (Andrades, Rosenthal, 
Carroll, Baranano, Peters, 2008;  Day, Beck, Deep, et al, 2013;  Day, Beck, Heath, et al, 2013;  
Day, Sweeny, et al, 2013;  Heath, et al).  Intraoperative imaging will be performed with optical 
imaging devices Novadaq SPY/LUNA;  Novadaq IR9000 Fluorescence Imaging System with 
Open-Field Handheld Fluorescence Imaging Camera and/or Pinpoint Endoscopic Fluorescence 
Imaging Camera;  and SurgVision Explorer Air multi-spectral fluorescence reflectance system. 
Margin analysis:  The sensitivity and specificity of these experiments will be determined based 
on histological confirmation of tumor within the margin specimens, as performed previously by 
us in preclinical models (Kulbersh, et al, 2007;  Withrow, et al, 2007;  Withrow, et al, 2008).  
Assessment of regional lymphatics.  Subjects undergoing treatment of pancreatic cancer 
routinely undergo removal of additional peripancreatic lymph nodes.  In subjects in whom this is 
required, lymphadenectomy will be performed according to the standard of care with imaging 
before and after removal of the lymph nodes in vivo.  Imaging results (categorical 
positive/negative) will be correlated with histopathological evidence of disease. 
Ex Vivo Fluorescent Imaging.  Once the tumor has been removed from the subject and sent for 
pathology review, additional imaging will be performed with non-significant devices of 
pathological specimen(s) using non-invasive imaging modalities that do not expose the subject to 
radiation or other interventions, or alter the standard pathological processing of the tissues.  
Normal waste tissues will also be imaged.  The research imaging modalities will not be used in 
the patient-care setting.  Imaging will be done in collaboration with the Department of Pathology 
to ensure preservation of tumor-related information.  Data from the research use of the device 
will not be used for diagnosis or other medical decision-making..  
Sensitivity and specificity can be calculated from the frozen sections obtained (if removed as part 
of the standard of care procedure).  Once removed, the dimensions and weight of the specimens 
will be recorded to correlate with tumor fluorescence parameters with the presence or absence of 
tumor based on final pathological reading.  If tumor is present in the specimen quantification of 
tumor of the largest piece of tumor in two dimensions (mm x mm) will be performed by a board 

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certified pathologist.  A small biopsy of the primary tumor from the main specimen will also be 
included in the fluorescence and pathological analysis as a positive control.  Sensitivity, 
specificity, positive predictive value and negative predictive value will be determined as 
previously described by us (Rosenthal, et al, 2006;  Rosenthal, et al, 2007).  
Statistical considerations:  The linear relationship between fluorescence and tumor size will be 
computed as Spearman’s correlation coefficient.  The bias present between the measurements 
will be expressed in relationship to the tumor weight/size and fluorescence expressed as the 
mean difference with a 95% confidence interval.  Continuous variable means (eg, fluorescence 
intensity) will be compared to histological quantification of tumor as measured by the greatest 
dimension identified on the histopathological assessment.  Experiments will be performed as 
previously described using this method in preclinical models (Kulbersh, et al, 2007;  
Rosenthal, et al, 2007). 
Pathological correlates:  To determine biological characteristics associated with fluorescence 
intensity, paraffin embedded blocks from the primary tumor will be obtained from pathology 
after routine analysis and these histological imaged by the Pearl and Odyssey (LiCor, Lincoln, 
NE) as previously described in preclinical models (Heath, et al.).  Histological sections will also 
undergo analysis for:  1) size of the epithelial tumor compartment in percent of total, 2) tumor 
viability, and 3) EGFR immunohistochemistry.  Methods have been previously described by us 
using in vivo models (Gleysteen, et al, 2007b;  Kulbersh, et al, 2007;  Rosenthal, et al, 2006;  
Rosenthal, et al, 2007;  Withrow, et al, 2007).  These parameters will be correlated with 
fluorescence intensity from the Pearl and Odyssey imaging systems.  
Ex Vivo Photoacoustic Imaging (PAI).  The PAI device is a hand-held device (Figure 3) created 
at Stanford University in the Gambhir’s laboratory.  PAI provides optical contrast ultrasound 
images with high spatial and temporal resolution.  PAI employs rapid short light pulses to 
illuminate tissue.  The light is absorbed by various endogenous molecules (eg, hemoglobin) 
leading to minute changes in temperature, which in turn, cause the absorbing molecules to 
locally expand.  The transient local tissue expansion generates a pressure wave (sound) that 
can be detected using an ultrasound imaging system.  To enhance the contrast further, 
exogenous contrast (eg, IRDye800) can be used (Figure 3b).  This instrument provides real-time, 
non-invasive imaging of tissues at depths of up to 5 cm at impressive clarity 
(Kothapalli, et al, 2012) (See also Appendix D).  The average signal intensity (or more 
specifically the signal-to-noise ratio measured in dB) of the tumor will be calculated in the 
region of interest (ROI) and compared to normal surrounding tissue.  

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a. 
 
b.  
 c.
 
Figure 3. a.  Photoacoustic imaging (PAI) hand-held device.  
b.  PAI principle.   
c.  Phantom study of PA signal of IRDye800, showing proper PA signal even at  
     low concentrations 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
3.1 
Inclusion Criteria 
a) Clinically suspected or biopsy-confirmed diagnosis of pancreatic adenocarcinoma. 
b) Planned standard of care surgery with curative intent for pancreatic adenocarcinoma. 
c) Age ≥ 19 years 
d) Life expectancy of more than 12 weeks 
e) Karnofsky performance status of at least 70% or ECOG/Zubrod level 1 
f) Hemoglobin ≥ 9 gm/dL 
g) Platelet count ≥ 100,000/mm3  
h) Magnesium, potassium and calcium > the lower limit of normal per institution normal lab 
values 
i) TSH < 13 micro International Units/mL 
3.2 
Exclusion Criteria 
a) Received an investigational drug within 30 days prior to first dose of 
Cetuximab-IRDye800 
b) Myocardial infarction (MI);  cerebrovascular accident (CVA);  uncontrolled congestive 
heart failure (CHF);  or unstable angina within 6 months prior to enrollment 
c) History of infusion reactions to cetuximab or other monoclonal antibody therapies 
d) Pregnant or breastfeeding 
Light input 
To interface board 
Fiber optic bundle 
PCB cable 
CM
PCB front 
PCB 
E
PDMS 

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e) Evidence of QT prolongation on pretreatment ECG (greater than 440 ms in males or 
greater than 450 ms in females) 
f) Lab values that in the opinion of the primary surgeon would prevent surgical resection. 
g) Patients receiving Class IA (quinidine, procanamide) or Class III (dofetilide, amiodarone, 
sotalol) antiarrhythmic agents. 
3.3 
Informed Consent Process 
All participants must be provided a consent form describing the study with sufficient information 
for participants to make an informed decision regarding their participation.  Participants must 
sign the IRB-approved informed consent prior to participation in any study specific procedure.  
The participant must receive a copy of the signed and dated consent document.  The original 
signed copy of the consent document must be retained in the medical record or research file.  
3.4 
Registration Process 
To register the subject, the study site will call the Stanford Study Coordinator at:                    ,  
Monday through Friday, between 9:00 am and 5:00 pm (Pacific time).  The individual making 
the phone call will provide the subject’s eligibility information at this time.  No subject may 
begin study treatment prior to registration, and assignment of a subject identification number. 
At registration, Stanford will sequentially assign eligible subjects a unique subject identification 
number.  As confirmation, Stanford will provide the Investigator with written verification of the 
subject’s registration by e-mail or fax.  The subject’s identification number will be used on all 
subject-specific Case Report Forms (CRFs) and serious adverse event (SAE) forms.  Participant 
information should be entered into Oncore within 7 days.  
3.5 
Study Timeline 
Primary Completion: 
The study will reach primary completion 24 months from the time the study opens to accrual. 
Study Completion: 
The study will reach study completion 24 months from the time the study opens to accrual.  
The anticipated study start date:  March 2016 
The anticipated study completion date:  March 2018 
4. 
TREATMENT PLAN 
4.1 
Treatment Schedule 
Patients will be randomized signed in 2 cohorts.  Cohort 1 will receive a 100 mg unlabeled 
test/loading dose of cetuximab and 50 mg of Cetuximab-IRye800.  Cohort 2 will receive a 
100 mg unlabeled test/loading dose of cetuximab and 100 mg of Cetuximab-IRDye800.   
Cohort 
Number of 
Patients 
Dose Cetuximab-
IRDye800 
Loading Dose 
unlabeled cetuximab 
Time between 
infusion and surgery 
1 
5 
50 mg 
100 mg 
2 to 5 days 
2 
5 
100 mg 
100 mg 
2 to 5 days 

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4.2 
Administration of Cetuximab-IRDye800 
A test/loading dose of 100 mg of unlabeled cetuximab will be administered via a 30-minute 
IV infusion, starting about 1 hour prior to infusion of the Cetuximab-IRDye800.  A fixed dose of 
100 mg will be given prior to surgery.  Because the pharmacokinetics of cetuximab are 
well-known and the dosing is in the sub-therapeutic range, only limited pharmacokinetics will be 
performed (Tan, et al, 2006).  Blood levels will be monitored before infusion (up to 30 days 
before) and after infusion (2 hours);  on Day 1 as available;  on Day 3 to 10;  and Day 15 to 30.  
The half-life of cetuximab is known to be 4.5 days (package insert), however, single 
administration of low doses in humans results in significantly shorter half-life (Tan, et al, 2006).  
With a single dose at the levels proposed the half-life is expected to be approximately 2 to 3 
days.  Clearance of cetuximab occurs through the binding in the liver and through the 
reticuloendothelial system as occurs with endogenous immunoglobulin. 
Prior to the test/loading dose, patients will be pre-medicated with an antihistamine 
(eg, diphenhydramine 50 mg IV) and any other medication as deemed appropriate by the treating 
physician prior to first dose.  Treatment will be given in an infusion facility that routinely 
administers cetuximab and is equipped with emergency equipment and medication along with 
medical personnel in the event that the patient experiences a severe reaction.  
If a subject experiences a clinically-important reaction to the test dose of unlabeled cetuximab, 
then the subject will be discontinued and withdrawn from the study, and will not receive the 
study drug Cetuximab-IRDye800.  The test dose will be given according to the routine protocol 
for cetuximab infusion.  The infusion will be stopped if deemed necessary with the onset of any 
significant signs of reaction.  Steroids and other supportive medications may be administered and 
infusion resumed at the discretion of the treating physician.  If a patient experiences a serious 
reaction that prevents receiving the entire test dose of cetuximab, the patient will be observed;  
but  will not continue on-study to receive the study drug Cetuximab-IRDye800 .  Any patient 
who does not receive the Cetuximab-IRDye800 will be considered a screen failure.  
Administration of Cetuximab-IRDye800 will be performed consistent with institutional policy 
for administration of cetuximab.  The solution will not be diluted or mixed with any other 
medications.  Administration of Cetuximab-IRDye800 will occur by IV over 
30 minutes to 1 hour.  Patients will be observed for 3 hours after administration.  Additional 
treatment for electrolyte imbalances will be given following institutional policy. 
4.3 
Definition of Dose-limiting toxicity (DLT) and Cohort Expansion 
AEs will be graded according to the CTCAE v4.0 (http://evs.nci.nih.gov/ftp1/CTAE/about.html). 
Dose-limiting toxicity (DLT) will be defined as any Grade 2 or greater toxicity that is ALL of 
the following: 
 
Determined by the investigator to be possible, probably or definitely-related to 
Cetuximab-IRDye800  
 
Considered by the Investigator to clinically significant for patients who received 
Cetuximab-IRDye800.  For this study, clinically significant is defined based on NCI 
definition – a result that is large enough to affect a patient’s disease state in a manner that is 
noticeable to the patient and/or caregiver or requires intervention. 
 
Occurred within 15 days of receiving treatment with Cetuximab-IRDye800.  

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If a DLT is experienced, an additional 5 subjects will be added to that same dose level.  The 
Stanford DSMC will be notified of all DLTs.  The DSMC will evaluate safety data from all 
subjects through Day 15.  If it is determined by the DSMC that the dosing is safe in the cohort 
where the DLT was experienced, the next higher dose level may be assigned and enrollment 
resumed.  
4.4 
Surgical Imaging 
Tumor assessment.  Please see previous section (3.0 Study Design) for more detail.  The tumor 
will be imaged using the optical imaging systems.  The primary tumor will be imaged prior to 
surgical resection, then the wound bed will be imaged after surgical resection, and then the 
primary tumor and frozen section margins imaged on ‘back table’ prior to sending to pathology.  
The information obtained from the imaging device or the images itself will not be used for 
diagnosis or any other medical decision-making.  Added surgical time for these images is 
expected to be minimal since these the images can be recorded for later review as still and video 
images.  Any additional lymphadenectomy specimen will be imaged prior to pathological 
analysis.  Suspected positive nodes will be tagged with a surgical clip for correlation with 
positivity in pathological review.  Once the specimens have been delivered to pathology, 
additional imaging will be performed as described above. 
Imaging of the tumor specimens in situ will allow for calculation of tumor to background 
ratio (TBR).  The fluorescence intensity of the tumor is compared to the grossly normal tissue 
imaged within the field and provides an assessment of Cetuximab-IRDye800 uptake within the 
tumor compared to normal tissues.  Multiple measurements can be obtained at the time of 
surgery from still images and histograms for regions generated using ImageJ (NIH) as we have 
previously described (Heath, et al). 
4.5 
General Concomitant Medication and Supportive Care Guidelines 
Other than chemotherapy (including any EGFR targeting agent), subjects may continue any 
medication they are receiving at study entry for underlying medical conditions.  All medications 
taken at time of study entry will be recorded.  Any changes in concomitant medication, including 
additions, discontinuations, and dose changes, occurring during the study will be recorded. 
4.6 
Criteria for Removal from Study 
Treatment will be stopped and patients will be removed from study due to unacceptable AEs, or 
withdrawal of consent.  
4.7 
Alternatives and Risk Protection / Mitigation  
Alternatives 
 This study is in the setting of tumor excision of biopsy-confirmed diagnosis of HNSCC, 
and the experimental component is infusion of Cetuximab-IRDye800, which may help 
visualize the tumor and tumor margins for the surgeon.  The surgery itself is considered 
regular medical care.  Therefore, the alternative to participating in this study is to have 
the tumor excision surgery without the Cetuximab-IRDye800 infusion.  

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Procedures to protecting against and minimize potential risks:  
 This study is designed enroll appropriate patients populations (see Section 3.1 
Inclusion Criteria, and Section 3.2 Exclusion Criteria).  
 Subjects will be monitored regularly by the investigators and the study team after 
investigational Cetuximab-IRDye800 and surgery, through 30 days (± 1 week) 
post-Cetuximab-IRDye800 treatment, for AEs by means of physical exams, blood tests, 
and scans.  
 Subjects will be given a 24-hour emergency number in case problems arise between 
clinic visits. 
 Subject records will be kept in a secure location at Stanford University Medical Center 
accessible only to authorized personnel. 
5. 
INVESTIGATIONAL AGENT INFORMATION 
5.1 
Description of Study Drug   
Cetuximab (Erbitux) is a recombinant human/mouse chimeric monoclonal antibody that binds 
to the extracellular domain of the human EGFR and functions as an antagonist by competitively 
inhibiting binding of Epidermal Growth Factor.  Cetuximab is composed of the Fv regions of the 
murine anti-EGFR antibody with the human igG1 heavy and kappa light chain constant regions.  
The molecular weight of this recombinant antibody is approximately 152,000 kDa.  Cetuximab is 
produced in murine myeloma cell culture and is supplied as a sterile solution at 2.0 mg/mL.  The 
buffered solvent is 8.48 mg/mL sodium chloride, 1.88 mg/mL sodium phosphate dibasic 
heptahydrate, and 0.41 mg/mL sodium phosphate monobasic monohydrate without preservatives 
and with a pH between 7.0 and 7.4. 
Cetuximab has been FDA-approved since 2006 for use in combination with radiation therapy for 
treatment of locally or regionally advanced squamous cell carcinoma.    Cetuximab has also been 
approved for monotherapy or in combination with chemotherapeutic agents in colorectal cancer 
since 2004.  As a result of almost a decade of use, its properties are well described, including its 
toxicity profile.  Adverse reactions primarily include infusion reactions (20%), cutaneous (rash 
90% and dry skin/pruritus 40 to 50%), CNS (fatigue 90% and headache 33%), hypomagnesium 
(55%), and gastrointestinal (abdominal pain 60%).  Many of the reported AEs are associated 
with repeat administration rather than single dose as proposed in the current study.  Infusion 
reactions are the most likely AE to be encountered in this study from cetuximab alone.  We 
propose a test/loading dose of unlabeled cetuximab in order to determine if the subject has 
hypersensitivity to the unmodified monoclonal antibody. 
The mean half-life of cetuximab is 112 hours and appears to plateau at does greater than 
200 mg/m2.  Although the half-life of cetuximab when given in multiple doses is known to be 
112 hours (4.7 days;  cetuximab package insert), the half-life of cetuximab has non-linear 
kinetics and is significantly shorter when administered as a single dose.  Studies have shown that 
when administered to humans at 50 mg/m2, measurable concentrations of cetuximab could not be 
detected beyond 96 hours (4 days) and when administered at 100 mg/m2 measurable 
concentrations of cetuximab could not be detected beyond 168 hours (7 days) (Tan, et al, 2006). 

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IRDye800CW 
IRDye® 800CW N-hydroxysuccinimide (NHS) ester infrared dye (LiCor, Lincoln, NE) has a 
molecular weight of 1166 Da and is supplied as a lyophilized powder.  It can be dissolved in 
water or DMSO at concentrations up to 20 mg/mL.  The dye in 1:1 solution of Phosphate 
Buffered Saline (PBS):  methanol has an absorbance maximum of 777 nm and an emission 
maximum of 791 nm.  IRDye800CW is a near infrared fluorescent imaging dye that can be 
easily bound to proteins through the NHS Ester group (Figure 4) and has emission and 
absorption wavelengths as described in Figure 5.  Much of the information around IRDye800 
remains proprietary, however, LiCor has filed a master drug file with FDA (MF 25167) and 
produces the dye under cGMP conditions with appropriate documentation.  
 
Figure 4.  IRDye800CW NHS Ester.  Molecular formula and molecular characteristics 

IRB-35789 
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Figure 5.  Absorption and emission spectra of IRDye800.  Peak absorbance occurs at 773 nm 
and the peak emission is detected at 782 nm. 
IRDye800CW has not been formally tested in humans and is not FDA-approved.  IRDye800CW 
has been assessed in rodents at 20 mg/kg without noticeable toxicity (Marshall, Draney, 
Sevick-Muraca, Olive).  This dose is several hundred times the proposed dose in the current trial.  
Although there are currently no publications available to demonstrate use of bioconjugated 
IRDye800, bevacizumab (Avastin) conjugated to IRDye800 is currently under investigation in 
Europe (http://clinicaltrials.gov/ct2/show/NCT01508572), but has not been tested in the US in 
any form that we are aware of, and is not approved for any indication.  There have been no AEs 
associated with the administration of the bevacizumab-IDye800 (personal communication with 
Principal Investigator Dr van Dam).  
Cetuximab-IRDye800 
Cetuximab-IRDye800 is produced by mixing the two components in phosphate buffer at pH 8.5 
and allowing the reaction to proceed at 20 to 25ºC.  The conjugation reaction is followed by a 
buffer exchange into pH 7.4 PBS.  The desired stoichiometry for the product is approximately 
1.5 dye molecules per antibody molecule.  Cetuximab-IRDye800 has been produced under 
cGMP conditions at University of Alabama at Birmingham using cGMP IRDye800CW and 
commercially available cetuximab.  Formal testing of the Cetuximab-IRDye800 for stability, 
sterility and antigen specificity is contained within the CMC section according to an FDA 
approved process.  The manufacturing and quality processes are documented elsewhere. 
Cetuximab-IRDye800 was recently evaluated in a phase 1 clinical trial for surgical navigation in 
head and neck cancer at the University of Alabama by Dr Rosenthal (Rosenthal, et al, 2015).  

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12 subjects participated in a dose-escalation study, receiving up to 62.5 mg/m2 
Cetuximab-IRDye800.  No grade 2 or higher AEs were attributed to Cetuximab-IRDye800.  This 
maximum dose (62.5 mg/m2) exceeds the dose that will be used in this study (50 or100 mg).  
There were very limited differences identified between cetuximab and Cetuximab-IRDye800, 
however there are several relevant findings: 
1. The study demonstrated that the pharmacokinetics of single dosing with 
Cetuximab-IRDye800 are very similar to cetuximab; both have half-life of 2.6 days when 
dosed at 250 mg/m2 in non-human primates.  Therefore data will be collected using the 
known pharmacokinetics of cetuximab.  
2. A small but statistically significant increase in the QTc interval was identified during the 
infusion of cetuximab or Cetuximab-IRDye800.  Therefore patients at risk for 
arrhythmias associated with QT prolongation will be excluded (see exclusion criteria). 
3. Phase 1 clinical trial data did not demonstrate a clinically significant Grade 2 reactions to 
Cetuximab-IRDye800 or was there a dose dependent relationship seen during the dose 
escalation of the study drug (Rosenthal, et al, 2015).  
5.2 
Expected Toxicities 
With the exception of infusion reactions and allergic responses, the toxicities associated with 
cetuximab-based therapy are usually dose dependent and associated with prolonged therapy.  
Because the cetuximab will be delivered at between 1/100 to ¼ the therapeutic dose and will 
only be administered once, we anticipate the primary AEs will be related to the infusion reaction 
or allergic response.  
5.2.1 Infusion Reaction 
Because the study proposes to administer a single sub-therapeutic dose, the most likely 
AE we anticipate is an infusion reaction.   Minor (Grade 1) infusion reactions from 
cetuximab can occur has high as 20%, with severe reactions (anaphylaxis) occurring in 
less than 1%.  Serious infusion reactions can occur, requiring medical intervention and 
immediate, permanent discontinuation of cetuximab include rapid onset of airway 
obstruction (bronchospasm;  stridor;  and hoarseness);  hypotension;  shock;  loss of 
consciousness;  myocardial infarction;  and/or cardiac arrest.  Severe (NCI CTC Grades 3 
and 4) infusion reactions occurred in 2 to 5% of 1373 study subjects receiving cetuximab, 
with fatal outcome in 1 subject. 
5.2.2 Allergic Response 
The Cetuximab-IRDye800 bioconjugate may provoke an allergic response since the 
humanized antibody has been modified.  Although possible, we consider an allergic 
response unlikely because the agent is given as a single dose-limiting immunogenic 
potential (sensitization not possible) and similar antibody bioconjugates (radiolabeled 
antibodies) are given routinely without report of this complication.  Blood will be 
collected for future analysis of antibodies that develop against the study drug. 
5.2.3 Cardiac Toxicity 
Cardiopulmonary arrest and/or sudden death occurred in 4 (2%) of 208 subjects treated 
with radiation therapy alone in a previous study.  Three patients with prior history of 

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coronary artery disease died at home, with myocardial infarction as the presumed cause 
of death.  This toxicity is not widely reported in other studies. 
Prolonged QT interval:  Preclinical studies in non-human primates in non-human 
primates identified an increase in the QTc interval for cetuximab and 
Cetuximab-IRDye800.  There was also a statistically significant difference between the 
QTc interval between the cetuximab and Cetuximab-IRDye800 that will require 
assessment of interval ECG and exclusion criteria of patients at risk for arrhythmias, see 
exclusion criteria.  Screening ECG and intermittent ECG data will be obtained as part of 
the study. 
5.2.4 Pulmonary Toxicity 
Interstitial lung disease (ILD) including 1 fatality has occurred in patients receiving 
cetuximab.  Interrupt cetuximab for acute onset or worsening of pulmonary symptoms.  
Permanently discontinue for confirmed ILD.  
5.2.5 Dermatologic Toxicity 
Dermatologic toxicities, including acneiform rash;  skin drying and fissuring;  
paronychial inflammation;  infectious sequelae (eg, S aureus sepsis;   abscess formation;  
cellulitis;  blepharitis;  conjunctivitis;  keratitis/ulcerative keratitis with decreased visual 
acuity;  cheilitis);  and hypertrichosis occurred in patients receiving cetuximab.  Severe 
acneiform rash occurred in 1 to 17% of patients. 
Acneiform rash usually developed within the first two weeks of therapy and resolved in a 
majority of the patients after cessation of treatment, although in nearly half, the event 
continued beyond 28 days.  Monitor patients receiving cetuximab for dermatologic 
toxicities and infectious sequelae.  Patients should be instructed to limit sun exposure 
during cetuximab therapy.  
5.2.6 
Hypomagnesemia and Electrolyte Abnormalities  
Hypomagnesemia occurred in patients receiving cetuximab, especially when given in 
combination with chemotherapy.  The onset of hypomagnesemia and accompanying 
electrolyte abnormalities occurred days to months after initiation of cetuximab.  
Periodically monitor patients for hypomagnesemia, hypocalcaemia, and hypokalemia, 
during and for at least 48 to 72 hours following the completion of cetuximab.  Replete 
electrolytes as necessary using guidelines in Section 4.2.2.  
5.2.7 
Other Toxicities 
It is also possible that other cetuximab related toxicities will appear (fatigue or diarrhea), 
but because the proposed dose is a fraction of the therapeutic dose and is administered 
only once, these are likely not to be the dose-limiting toxicities in this clinical trial.  We 
do not expect significant toxicities from IRDye800 because rodent toxicology studies 
have not demonstrated toxicity (Marshall, et al), and it has similar chemical structure as 
indocyanine green (which has been delivered to humans in gram quantities for decades 
without significant toxicity.  

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5.3 
Study Drug Discontinuation / Study Withdrawal  
Study drug will be discontinued for any of the following: 
1. 
Subject withdraws consent for the study 
2. 
Death attributed to study drug 
3. 
Serious systemic anaphylactic reaction (Grade 3)  
4. 
Any serious rare reactions attributed to study drug 
5. 
Subject experiences a serious reaction to the test/loading of cetuximab (ie, unable to 
continue and receive study drug Cetuximab-IRDye800).  Because subjects who 
discontinue pursuant to this clause will not have received Cetuximab-IRDye800, 
these subjects will NOT be counted towards the accrual target defined at 
12.1 Statistical Design / Sample Size.  
If one of these events occurs, and is a serious adverse event (SAE, ie, 2, 3, or 4 above), the FDA, 
IRB and Stanford DSMC will be notified immediately and there will be a comprehensive review 
of the safety data prior to resuming and further study drug administration. 
5.4 
Availability 
Unlabeled cetuximab will be sourced commercially  
Cetuximab-IRDye800 has been produced under cGMP conditions at University of Alabama at 
Birmingham using cGMP IRDye800CW and commercially available cetuximab.  Formal testing 
of the Cetuximab-IRDye800 for stability, sterility and antigen specificity is contained within the 
CMC section according to an FDA approved process.  The manufacturing and quality processes 
are documented elsewhere. 
5.5 
Agent Ordering 
University of Alabama at Birmingham will ship the Cetuximab-IRDye800 to be stored at the 
Stanford Investigational pharmacy under a material transfer agreement.  Investigational 
pharmacy will be responsible for storage and dispensing of the drug following a standard 
institutional process after the patient is screen and enrolled on the study.  Sufficient amounts of 
the Cetuximab-IRDye800 are available for this clinical trial. 
The unlabeled cetuximab will dispensed by the investigational pharmacy to the study.  
5.6 
Agent Accountability 
The investigator will be responsible for the accounting of Cetuximab-IRDye800.  The 
documentation of lot numbers, dose and administration records and storage of drug will be the 
responsibility of the Investigator as well, and are described in detail in the CMC documentation.  
The investigator will be responsible for ensuring study drug is correctly labeled and the 
appropriate dose provided per the protocol.  
6. 
DOSE MODIFICATIONS 
Apart from dose escalation already discussed in Section 4.3 there are no other dose modification 
allowed in this study. 

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7. 
ADVERSE EVENTS AND REPORTING PROCEDURES 
7.1 
Adverse Event (AE) 
An adverse event (AE) is any event that is presents during the trial that was not observed at 
baseline or has worsened from baseline. 
7.2 
Serious Adverse Event 
A SAE is defined (21CFR312.32) as any adverse experience that suggests a significant hazard, 
contraindication, side effect, or untoward medical occurrence that: 
 Results in death, 
 Is life-threatening (Note:  the term “life-threatening” refers to an event in which the 
subject was at risk of death at the time of the event rather than to an event which 
hypothetically might have caused death if it were more severe), 
 Requires (or prolongs) hospitalization, 
 Causes persistent or significant disability/incapacity, 
 Results in congenital anomalies or birth defects, or 
 Other conditions which in the judgment of the Investigator represent significant hazards 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life-threatening or result in death or hospitalization, but may jeopardize the subject, or may 
require intervention to prevent one of the other outcomes listed in the above definition.  These 
should be considered serious. 
Any pregnancy which occurs during this clinical trial must be reported to the Sponsor and treated 
as a SAE with regard to the reporting time line.  Any pregnancy must be followed until 
conclusion of the pregnancy (delivery or termination).  Administration of study drug will be 
discontinued in a subject who becomes pregnant.  If a male subject reports a pregnancy of his 
spouse or significant other, data regarding the outcome of this pregnancy must be collected. 
7.3 
Assessment of Causality 
For any AE that occurs during this study, it will be the responsibility of the Investigator to assess 
the relationship of the event to study treatment.  
For this clinical trial, the following criteria will be used: 
 Unrelated: There is no temporal relationship between the event and the administration of 
the study drug, and/or the event is clearly due to the subject’s medical condition, other 
therapies, or accident. 
 Possibly Related: There is some temporal relationship between the event and the 
administration of the study drug and the event is unlikely to be explained by the 
participant’s medical condition or other therapies. 
 Probably Related:  The temporal relationship between the event and the administration 
of the study drug is compelling, and the participant’s medical condition or other therapies 
cannot explain the event. 

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 Definitely Related:  The temporal relationship between the event and the administration 
of the study drug is compelling, the participant’s medical condition or other therapies 
cannot explain the event and the event follows a known or suspected response pattern to 
the medication. 
7.4 
Severity of Adverse Events 
AEs will be graded per NCI Common Terminology Criteria for Adverse Events (CTCAE v4.0) 
(http://evs.nci.nih.gov/ftp1/CTCAE/about.html). 
 Mild (Grade 1) 
 Moderate (Grade 2) 
 Severe (Grade 3) 
 Immediately life-threatening/Fatal (Grade 4 and 5) 
7.5 
Safety Monitoring and Reporting 
7.5.1 
Monitoring of Adverse Events 
AEs will be graded according to CTCAE v4.03.  Both serious and non-serious AEs will 
be clearly noted in source documentation and listed on study-specific Case Report 
Forms (CRFs).  The Protocol Director (PD) or designee will assess each AE to determine 
whether it is unexpected according to the Informed Consent, Protocol Document, or 
Investigator’s Brochure, and related to the investigation.  All SAEs will be tracked until 
resolution, or until 30 after the last dose of the study treatment.  
SAEs CTCAE Grade 3 and above, and all subsequent follow-up reports will be reported 
to the Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) using 
the study specific CRF regardless of the event’s relatedness to the investigation.  
Following review by the DSMC, events meeting the IRB definition of ‘Unanticipated 
Problem’ will be reported to the IRB using eProtocol within 10 working days of DSMC 
review, or within 5 working days for deaths or life-threatening experiences. 
All AEs, regardless of seriousness or relationship to study drug, including those occurring 
during the Screening period (where applicable), are to be recorded in the study-specific 
worksheets, with the following exceptions. 
 AEs that are solely laboratory values;  are not related to the study drug;  AND are 
clinically non-significant may not be collected.  
 Non-serious AEs that occur within 10 days after surgical resection of the tumor;  are 
not related to the study drug;  are not clinically significant;  AND are expected in the 
post-surgery clinical setting may not be collected. 
Whenever possible, symptoms should be grouped as single syndrome or diagnosis.  The 
Investigator should specify the date of onset, maximal intensity, corrective therapy given, 
outcome, and his/her assessment of causality. 
Any AE that is not resolved by the end of the study and considered to be potentially 
related to study drug, or was the cause for the subject’s withdrawal will be followed as 
clinically indicated until its resolution, or if non-resolving, until considered stable. 
7.5.2 
Recording and Reporting Adverse Events and Serious Adverse Events 

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It will be the responsibility of the Investigator to provide to the FDA all information  that 
is concerning for significant hazards, contraindications, side effects or precautions felt 
significant to the safety of the drug being studied.  Subjects will be instructed prior to 
participation on the importance of reporting any symptoms (new or worsening), and/or 
any physical changes throughout their participation in the study.  These events will be 
recorded accordingly in the CRF.  Abnormal laboratory and/or clinical assessments will 
also be captured in the appropriate CRF. 
All SAEs must be reported immediately (within 24 hours) from the time the Investigator 
learns of the event to the medical monitor.  All SAEs and deaths must be reported in this 
fashion regardless of their causality assessment to the study drug. 
Name:  
Mark D Pegram, MD 
Telephone:  
                   
Email:  
mpegram@stanford.edu  
In the event of a SAE, the Investigator must report provide a detailed description of the 
event, the treatment regimen, relevant laboratory and evaluations and assessment of the 
relationship of the AE to the study drug.  All relevant information should be reported as it 
becomes available.  
All SAEs (Grade 3 or above as graded by CTCAE v4.03) will be reported to the overall 
PI of the study at Stanford in writing within 5 business days of the event;  Stanford will 
promptly report SAEs to CCTO for forwarding as necessary to the Stanford IRB and 
DSMC.  
All SAEs must be reported to the FDA and IRB according to regulatory requirements.  
Any woman who becomes pregnant or suspects she is pregnant while participating in the 
study must inform her treating physician and the Investigator immediately.  The 
pregnancy must be followed through delivery or final outcome.  This will also be true for 
any male who learn they may have impregnated a female while participating in the trial.  
8. 
CORRELATIVE/SPECIAL STUDIES  
Correlative studies will depend upon initial findings.  

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9. 
STUDY CALENDAR 
9.1 Study Procedures Table 
Enrolled subjects will follow schedule of evaluations provided below. 
 
SCREENING / 
PRE-TREATMENT (≤ 30 DAYS 
BEFORE TREATMENT) 
DAY 0 
DAY OF 
SURGERY
(DAY 2-5) 
DAY 10  
(±4 DAYS 12) 
DAY 30 
(±1 WEEK 12) 
INFORMED CONSENT 
X 
 
 
 
 
MEDICAL HISTORY 
X 
 
 
 
 
PHYSICAL EXAMINATION 1 
X 
X 
 
X 
X 
VITAL SIGNS 
X 
X 
X 
X 
X 
PERFORMANCE STATUS 1 
X 
X 
 
X 
X 
ECG 
X 2 
X 2 
 
 
X 
CHEMISTRIES 3 
X 
X 
X 
 
X 
HEMATOLOGY 4 
X 
 
 
 
X 
TSH 
X 
 
 
 
 
PTT/PT/INR 
X 
 
 
 
 
SERUM PREGNANCY 13 
X 
X 13 
 
 
 
PK - FLUORESCENT-LABELED 
ANTIBODY 5 
 
X 
X 
X 
X 
PK-IMMUNOGENICITY 6 
 
X 
 
 
X 
IV INFUSION OF CETUXIMAB 
(100 MG LOADING DOSE) 7 
 
X 
 
 
 
IV INFUSION OF 
CETUXIMAB-IRDye800 8 
(AFTER COMPLETION OF 
TEST DOSE) 
 
X 
 
 
 
SURGICAL RESECTION 
 
 
X 
 
 
TUMOR IMAGING 
 
 
X 9 
 
 
PATHOLOGICAL 
EVALUATIONS 10 
 
 
X 
 
 
ADVERSE EVENTS 
 
X 
X 
X 
X 
CONCURRENT MEDICATIONS 
X 
X 
X 
X 
X 
1. A physical examination and performance status assessment will be done at Screening;  Day 0;  ;  Day 6 to14;  and 
Day 23 to37.  Examinations collected for surgical procedure are acceptable for screening purposes.  Examinations do 
not have to be repeated on Day 0 if completed within 14 days of infusion. 
2. ECG will be obtained at screening to evaluate baseline and then at 30 minutes and 2 to 3 hours after initiation study 
drug infusion.  A previous ECG that was obtained as part of standard of care may be used as the baseline ECG as long 
as it was obtained within 30 days of the start of treatment. 
3. Chemistries include:  Na+;  K+;  CO2;  Cl;  Mg++;  Ca++;  BUN;  Cr;  Phosphorus;  albumin;  alkaline phosphatase;  
ALT;  AST;  total bilirubin;  total protein.  Labs drawn as part of the subject’s standard of care for surgery may be used 
for screening.  Chemistries do not have to be repeated on Day 0 if completed within 14 days of infusion. 
4. Hematology values include CBC and platelet count.  Labs drawn as part of the subject’s standard of care for surgery 
may be used as the baseline hematology values as long as they are within two weeks of treatment. 

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5. Serum level of cextuximab-IRDye800 will be drawn at baseline prior to loading dose;  2 hours after administration;  
Day 6 to14 and Day 23 to37to assess circulating fluorescent-labeled antibody and unconjugated dye.  This time point 
will be Day 23 to37, but will be abbreviated as 15 days throughout the protocol. 
6. Blood will be obtained pre-infusion and at 30 days after infusion and banked for future immunogenicity testing. 
7. To be given over 30 minutes followed by a 30 minute observation period prior to administration of the labeled 
Cetuximab.  Subjects will continue on-study if they successfully receive the loading/test dose.  
8. Infusion of Cetuximab-IRDye800 to be given over one hour followed by a three hour observation period. 
9. Tumors will be imaged intraoperatively using the optical imaging devices Novadaq SPY/LUNA;  IR9000 Fluorescence 
Imaging System with Open-Field Handheld Fluorescence Imaging Camera and/or Pinpoint Endoscopic Fluorescence 
Imaging Camera;  or SurgVision Explorer Air multi-spectral fluorescence reflectance system to determine threshold of 
detection.  Surgery is performed 2 to 5 days after infusion of study drug. 
10. All resected tissues will be evaluated for NIR fluorescence and photoacoustic signal prior to pathological examination. 
11. The Day 1 visit will be performed based on subject availability.  
12. Based on the subject’s standard of care admission or return visit 
13. Serum pregnancy test will be obtained on all women of childbearing age at baseline;  a urine pregnancy test will be 
performed on Day 0 if the result of a serum pregnancy test within 72 hours before administration of 
Cetuximab-IRDye800 is not available.  
9.2 Study Procedures  
The following evaluations and procedures will be performed: 
9.2.1 Screening/Pre Treatment (Within 30 days of treatment start) 
 Obtain written informed consent 
 Medical history including current medications 
 Assessment of performance status 
 Physical examination 
 Vital signs to include blood pressure;  heart rate;  respiratory rate;  temperature 
 Height and weight 
 Chemistries (electrolytes;  total bilirubin;  ALT;  AST;  alkaline phosphatase;  serum 
albumin;  creatinine;  BUN;  magnesium;  phosphorus).  Labs drawn as part of the 
subject’s standard of care for surgery may be used as the baseline chemistries as long as 
they are within two weeks of treatment. 
 CBC and platelets – labs drawn as part of the subject’s standard of care for surgery may 
be used as the baseline values as long as they are within two weeks of treatment 
 TSH 
 PTT/PT/INR – labs drawn as part of the subject’s standard care for surgery may be used 
as the baseline values as long as they are within two weeks of treatment  
 Serum pregnancy test for women of childbearing potential 
 ECG  
9.2.2 Day 0 
 Physical examination (within 14 days) 
 Vital signs to include blood pressure;  heart rate;  respiratory rate;  temperature 
 Performance status (within 14 days) 
 Chemistries (electrolytes;  total bilirubin;  ALT;  AST;  alkaline phosphatase;  serum 
albumin;  creatinine;  BUN;  magnesium;  phosphorus;  within 14 days) 

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 Pregnancy test for women of childbearing potential.  If the result of a serum pregnancy test 
within 72 hours before administration of Cetuximab-IRDye800 is not available, a urine pregnancy test will 
be performed on Day 0 
 Blood sample for Cetuximab-IRDye800 antibody prior to infusion 
 Blood sample for future assessment of immunogenicity 
 IV infusion of cetuximab (100 mg) over 30 minutes 
o Vital signs (blood pressure;  heart rate;  respiratory rate;  temperature) during 
infusion at 15 minutes and 30 minutes 
o Observation for 30 minutes 
o Vital signs (blood pressure;  heart rate;  respiratory rate;  temperature) 
post-infusion at 15 minutes and 30 minutes 
o Assessment for AEs 
o Assessment for concomitant medications  
o ECG will be obtained 30 minutes post-initiation of loading dose 
 Post-cetuximab infusion observation period of 30 minutes  
 IV infusion of Cetuximab-IRDye800 over 30 minutes to 1 hour  
o Vital signs (blood pressure;  heart rate;  respiratory rate;  temperature) during 
infusion at 15 minutes;  30 minutes;  and 60 minutes  
o Observation for 2 to 3 hours 
o Vital signs (blood pressure;  heart rate;  respiratory rate;  temperature) 
post-infusion at 15 minutes;  30 minutes;  60 minutes;  90 minutes;  2 hours;  and 
prior to discharge 
o Blood sample for Cetuximab-IRDye800 antibody 2 hours after completion of 
infusion 
o Assessment for AEs 
o Assessment for concomitant medications 
o ECG will be obtained 2 to 3 hours post-initiation of the study drug  
9.2.3 Day 2-5 (Day of Surgery) 
 Vital signs to include blood pressure;  heart rate;  respiratory rate;  temperature prior to 
surgery  
 Chemistries (electrolytes;  total bilirubin;  ALT;  AST;  alkaline phosphatase;  serum 
albumin;  creatinine;  BUN;  magnesium;  phosphorus)  
 Blood sample for fluorescent-labeled antibody  
 Scheduled routine surgical resection 
 Intraoperative tumor imaging 
 Pathological evaluations 
 Assessment for AEs 
 Assessment for concomitant medications 
9.2.4 Day 10 (+/- 4 days) 
 Physical examination  
 Vital signs to include blood pressure;  heart rate;  respiratory rate;  temperature 
 Performance status 
 Blood sample for fluorescent-labeled antibody 

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 Assessment for AEs 
 Assessment for concomitant medications 
9.2.5 Day 30 (+/- 1 week) 
 Physical examination  
 Vital signs to include blood pressure;  heart rate;  respiratory rate;  temperature 
 Performance status  
 Chemistries (electrolytes;  total bilirubin;  ALT;  AST;  alkaline phosphatase;  serum 
albumin;  creatinine;  BUN;  magnesium;  phosphorus)  
 CBC and platelets 
 Assessment for AEs 
 Assessment for concomitant medications 
 Obtain blood sample for fluorescent-labeled antibody and future assessment of 
immunogenicity. 
 ECG 
9.3 Description of Evaluations / Procedures  
9.3.1 Laboratory Evaluations:  Blood specimens will be collected for CBC;  platelets;  
electrolytes;  total bilirubin;  ALT;  AST;  alkaline phosphatase;  serum albumin;  
creatinine;  BUN;  magnesium and phosphorus;  PTT/PT/INR and serum pregnancy if 
necessary.  Blood will be taken for fluorescent-labeled antibody pharmacokinetics and 
blood will be obtained and banked for future analysis of immunogenicity against the 
study drug;  as requested by the FDA in pre-IND conversations.  
9.3.2 Physical Examinations:  A physical examination will be conducted to include review of 
all major systems prior to enrollment to study.  Standard abdominal examination and 
system-oriented physical examination will be conducted on other visits. 
9.3.3 Medical History:  A complete medical history including age;  sex;  race;  current 
medications;  any current or previous medical conditions;  any previous surgeries;  
smoking history;  alcohol use will be done at screening. 
9.3.4 Vital Signs:  Vital signs including blood pressure;  heart rate;  respiratory rate;  and 
temperature will be collected at each clinic visit.  Height and weight will be collected at 
screening. 
9.3.5 Cardiac Monitoring:  An ECG will be obtained during the screening period;  at Day 0 
during and after the infusion;  and then at Day 30.  QT/QTc interval will be assessed for 
each time point. 
 

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10. 
MEASUREMENTS 
For clinicaltrials.gov and Stanford Clinical Trials Directory compliance  
10.1  Primary Outcome Measure 
The primary objective of the study is to determine the efficacy of Cetuximab-IRDye800 to 
identify cancer compared to surrounding normal tissue 
Outcome measure:  Tumor to background ratio (TBR) and signal-to-noise ratio (SNR).  
Fluorescence and photoacoustic intensity of tumor tissue compared to that of normal surrounding 
tissue.  
10.2  Secondary Outcome Measure 
The secondary objectives are to determine the safety profile and tolerability of Cetuximab 
conjugated to the optical dye, IRDye800CW (Cetuximab-IRDye800).  
 Outcome measure:  Number of Grade 2 or higher AEs which have been determined to 
be clinically significant and definitely, probably or possibly related 
 Time Frame:  Safety events will be recorded over the 30-day observation period   
 Safety Issue:  Yes 
11. 
MULTISITE REGULATORY CONSIDERATIONS 
The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will be the 
monitoring board for this study, please refer to the Data and Safety Monitoring Committee SOP 
for more information.  
11.1 
Monitoring plan 
The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will be the 
monitoring entity for this study 

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11.2 
Role of the Stanford Data and Safety Monitoring Committee (DSMC)  
The Stanford DSMC will have the following roles in this study: 
 The DSMC will audit study-related activities approximately once per year to determine 
whether the study has been conducted in accordance with the protocol, local standard 
operating procedures, FDA regulations, and Good Clinical Practice (GCP).  This may 
include review of the following types of documents participating in the study:  regulatory 
binders, case report forms, eligibility checklists, and source documents.  In addition, the 
DSMC will regularly review SAEs and protocol deviations from all sites associated with 
the research to ensure the protection of human subjects.  Results of the DSMC audit will 
be communicated to the IRB and the appropriate regulatory authorities at the time of 
continuing review, or in an expedited fashion, as needed.  
 If Cetuximab-IRDye800 is discontinued at any clinical site, further dosing will be 
suspended and the DSMC will be notified of the SAE within 24 hours.  The DSMC will 
conduct a comprehensive safety review of the safety data.  On approval of the DSMC, the 
study may resume at that dose level, or at a lower dose level determined by the DSMC to 
be the probable maximum tolerated dose (MTD).  
 If a DLT (see Section 5.2.4) occurs, the Stanford DSMC will be notified of the DLT.  An 
additional five subjects will be added to that same dose level.  
o At any dose level identified by the DSMC as the probable MTD, an additional 
five subjects may be enrolled at the probable MTD dose level, so that a minimum 
of 10 subjects is evaluated at that dose level.  
11.3 
Protocol Review and Amendments 
The protocol, the proposed informed consent and all forms of participant information related to 
the study (eg, advertisements used to recruit participants) will be reviewed and approved by the 
Stanford IRB and Stanford Cancer Institute Scientific Review Committee (SRC).  Any changes 
made to the protocol will be submitted as a modification and will be approved by the IRB prior 
to implementation.  The Protocol Director will disseminate the protocol amendment to all 
participating investigators.  Investigators will be expected to obtain IRB approval within 90 days 
for all amendments.  
11.4 
Data management  
The research coordinator at Stanford will be responsible for database records of subject data.  
The data will be kept in a database, under password protection with access limited to specific 
areas of the database.  A chart with all of the relevant research subject information will be 
maintained for each subject at each institution by the research coordinator for that specific 
institution.  Subject charts may be reviewed by Stanford PI and Study Coordinator for yearly 
audits.  
11.5 
Study Documentation 
The Protocol Director and participating site investigators will maintain adequate and accurate 
participant case histories with observations and other data pertinent to the study.  Original source 
documents will be transcribed to Case Report Forms (CRFs).  Source documents include hospital 
records, clinical charts, laboratory and pharmacy records, and recorded electronic data.  Stanford 
University will enter all the study related data in the OnCore portal. 

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The principal investigator will be responsible for maintaining the clinical protocol at Stanford 
University and  subjects’ study charts;  for reporting AEs that occur at UAB;  assuring that 
consent for subjects is obtained and documented;  and for obtaining and maintaining IRB 
approval at Stanford University.  The principal investigator will report all continuing renewals 
received for the study to the Sponsor / Stanford Protocol Director.  
12. 
STATISTICAL CONSIDERATIONS 
12.1 
Statistical Design 
The primary endpoint will be evaluated in the following 4 ways: 
In Vivo Fluorescent Imaging.  When imaging the tumor in vivo we will calculate the 
tumor-to-background ratio (TBR).  The fluorescence intensity of the tumor is compared to the 
grossly normal tissue imaged within the field and provides an assessment of 
Cetuximab-IRDye800 uptake within the tumor compared to normal tissues.  Multiple 
measurements can be obtained at the time of surgery from still images and histograms for 
regions will be generated using ImageJ (NIH) as we have previously described 
(Andrades, et al, 2008;  Day, Beck, Deep, et al, 2013;  Day, Beck, Heath, et al, 2013;  Day, 
Sweeny, et al, 2013;  Heath, et al.). 
Assessment of Regional Lymphatics:  Imaging results (categorical positive/negative) will be 
correlated with histopathological evidence of disease. 
Ex Vivo Fluorescent Imaging.  The variables will be correlated with tumor fluorescence 
parameters.  Sensitivity, specificity, positive predictive value and negative predictive value will 
be determined as previously described by us (Rosenthal, et al, 2006;  Rosenthal, et al, 2007).  
The linear relationship between fluorescence and tumor size will be computed as Spearman’s 
correlation coefficient.  
Pathological Correlates:  To determine biological characteristics associated with fluorescence 
intensity, paraffin embedded blocks from the tumor will be obtained after routine pathologic 
analysis and will undergo analysis for:  1) size of the epithelial tumor compartment in percent of 
total, 2) tumor viability, and 3) EGFR immunohistochemistry (Gleysteen, et al, 2007b;  
Kulbersh, et al, 2007;  Rosenthal, et al, 2006;  Rosenthal, et al, 2007;  Withrow, et al, 2007).  
Ex Vivo Photoacoustic Imaging (PAI).  The average signal intensity (or more specifically the 
signal-to-noise ratio measured in dB) of the tumor will be calculated in the region of interest 
(ROI) and compared to normal surrounding tissue. 
Direct Comparison of Fluorescent and Photoacoustic Imaging. 
The number and location of detected lesions by fluorescent and photoacoustic techniques will be 
recorded on a schematic case-report form (CRF).  This will be done to determine if both imaging 
techniques are complementary to each other and thereby of synergistic advantage for pancreatic 
cancer surgery.  
The secondary endpoint of the study is to determine the tolerability of cetuximab conjugated to 
the optical dye, IRDye800CW (Cetuximab-IRDye800).  The safety endpoints are type, 
incidence, severity, seriousness, and study treatment relatedness of AEs.  Descriptive statistical 
analysis of subject disposition, baseline characteristics, exposure to study drug, and AEs will be 
performed.  Descriptive statistics for continuous data will include mean, standard deviation, 

IRB-35789 
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median, minimum, and maximum values.  Frequencies and percentages will be used to 
summarize categorical data.  
Sample size.  We propose to enroll and treat 10 subjects with cetuximab-IRDye800 in this study.  
These 10 subjects will be assigned in two cohorts.  Cohort 1 (first 5 subjects) will receive a 
100 mg unlabeled test/loading dose of cetuximab and 50 mg of cetuximab-IRye800.  Cohort 2 
(the last 5 subjects) will receive a 100 mg unlabeled test/loading dose of cetuximab and 100 mg 
of cetuximab-IRDye800.  The rationale for these doses is based on preliminary results for our 
phase 1 clinical trial (Rosenthal, et al, 2015) which demonstrated that:  (a) 50 mg dose provides 
the highest tumor-to-background ratio compared to doses higher and lower, and (b) the 100 mg 
unlabeled test/loading dose is optimal in reducing normal tumor background.  Subjects who 
experience a serious reaction to the test dose of unlabeled cetuximab will not continue and 
receive Cetuximab-IRDye800, and will not be counted towards the study accrual target.  
Subjects who fail the cetuximab test dose will be accounted separately from the study cohorts.  
Animal models demonstrate a sensitivity of 92% and specificity of 100% using 
Cetuximab-IRDye800 (Kulbersh, et al, 2007).  We expect that for each subject approximately 
10-12 frozen sections will be obtained from the wound bed with a positive rate of 25% (Cook, 
Jones, Phillips, Soler Lluch, 1993;  McMahon, et al, 2003;  Woolgar Triantafyllou, 2005) 

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APPENDICES 
APPENDIX A:  Participant Eligibility Checklist  
A Participant Eligibility Checklist will be completed in its entirety for each subject prior to 
registration.  The completed, signed, and dated checklist will be retained in the subject’s study 
file and the study’s Regulatory Binder.  
The study coordinator, treating physician and an independent reviewer will verify that the 
participant’s eligibility is accurate, complete, and legible in source records.  A description of the 
eligibility verification process should be included in the EPIC or other Electronic Medical 
Record progress note.  
Protocol Title: 
Intraoperative Pancreatic Cancer Detection Using Multimodality Molecular 
Imaging  
Protocol Number: 
IRB-35789 /  PANC0024 
Principal Investigator: George Poultsides, MD 
II.  Subject Information: 
Subject Name/ID: 
 
Gender:    
 Male     
 Female 
III.  Study Information: 
SRC-approved 
 IRB-approved 
 Contract signed 
 
III.  Inclusion/Exclusion Criteria 
Inclusion Criteria 
(From IRB-approved protocol) 
Yes 
No Supporting Documentation* 
1. Biopsy-confirmed or suspected diagnosis of pancreatic 
adenocarcinoma 
 
 
      
2. Subjects diagnosed with any T stage that are 
scheduled to undergo surgical resection.  Subjects with 
metastatic disease or a new primary will be allowed 
 
 
      
3. Planned standard of care surgery with curative intent 
for pancreatic cancer 
 
 
      
4. Age ≥ 19 years 
 
 
      
5. Life expectancy of more than 12 weeks 
 
 
      
6. Karnofsky performance status of at least 70% or 
ECOG/Zubrod level 1 
 
 
      
7. Hemoglobin ≥ 9 gm/dL 
 
 
      
8. Platelet count ≥ 100,000/mm3  
 
 
      
9. Magnesium, potassium and calcium > the lower limit 
of normal per institution normal lab values 
 
 
      
10. TSH < 13 micro International Units/mL 
 
 
      

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9 August 2016 
 
Exclusion Criteria 
(From IRB-approved protocol) 
Yes 
No 
Supporting Documentation* 
1. Received an investigational drug within 30 days prior 
to first dose of Cetuximab-IRDye800 
 
 
      
2. Myocardial infarction (MI);  cerebrovascular 
accident (CVA);  uncontrolled congestive heart failure 
(CHF);  significant liver disease;  or unstable angina 
within 6 months prior to enrollment 
 
 
      
3. History of infusion reactions to cetuximab or other 
monoclonal antibody therapies 
 
 
      
4. Pregnant or breastfeeding 
 
 
      
5. Evidence of QT prolongation on pretreatment ECG 
(greater than 440 ms in males or greater than 450 ms 
in females) 
 
 
      
6. Lab values that in the opinion of the primary surgeon 
would prevent surgical resection 
 
 
      
7. Subjects receiving Class IA (quinidine, procanamide) 
or Class III (dofetilide, amiodarone, sotalol) 
antiarrhythmic agents 
 
 
      
*All subject files must include supporting documentation to confirm subject eligibility.  
The method of confirmation can include, but is not limited to, laboratory test results, 
radiology test results, subject self-report, and medical record review.  

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IV.  Statement of Eligibility 
By signing this form of this trial I verify that this subject is [
 eligible / 
 ineligible] for 
participation in the study.  This study is approved by the Stanford Cancer Institute Scientific 
Review Committee, the Stanford IRB, and has finalized financial and contractual agreements as 
required by Stanford School of Medicine’s Research Management Group.  
 
 
 
Treating Physician Signature: 
Date: 
Printed Name: 
 
 
Secondary Reviewer Signature: 
Date: 
Printed Name: 
 
 
Study Coordinator Signature: 
Date: 
Printed Name: 

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APPENDIX B:  IR9000 Fluorescence Imaging System, Novadaq 
The system is based on Novadaq’s commercial PINPOINT Endoscopic Fluorescence Imaging 
System (PC9000).  It is an in development complimentary product to the PINPOINT for open 
field imaging.  There are two configurations:  the Endoscopic Fluorescence Imaging System for 
IR (EFI-IR) and the Handheld Fluorescence Imaging System for IR (HH-IR).  
The EFI-IR is very similar to the commercial PINPOINT system with the following 
modifications:   
1. Different laser source and excitation wavelength in the Video Processor/Illuminator 
(VPI). 
a. Part of development is ensuring the new laser meets the 3R requirement for laser 
safety (as PC9000 does) 
b. 60601-1 Electrical Medical device safety compliance is assessed.  PINPOINT is 
60601-1 and EMC certified.  Leakage currents, surface temperature and hipot 
testing are run in house in accordance to the test methods prescribed in the IEC 
60601 standards to ensure continued compliance. 
2. An additional filter within the endoscopic camera.  
a. This is a passive part that does not affect safety. 
b. Camera is sterilizable by Sterrad. 
The other components of the EFI-IR system are identical to the PC9000 system including cart, 
medical grade monitor, medical video recorder, sterilizable light guide, and endoscopes.  
The handheld open field configuration, HH-IR, uses the same VPI as the EFI-IR.  The imaging 
head is a handheld unit containing the camera optics and sensor, and the illumination optics.  
Similarly to the EFI-IR system the HH-IR system will be assessed for Electrical Medical Device 
Safety and EMC compliance in comparison to an equivalent device that is currently undergoing 
certification.  The imaging head will be compatible with the ND3000, a sterile drape that is 
approved for use in the US with the SPY2000 system. 

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APPENDIX C:  Explorer Air, SurgVision  
Investigational Device 
The SurgVision Explorer Air (beta version) is a multi-spectral fluorescence camera, which is 
specifically-designed to detect fluorescence in human tissue with the highest sensitivity.  
A schematic overview is shown in Figure 1.  It consists of a camera head mounted to an 
adjustable arm and a medical cart carrying all hardware and the arm.  During surgery, the camera 
head is placed above the field of interest to detect and image fluorescence signals.  The camera 
operates at frame rates of 56 fps, which allows for imaging in real-time.  Due to the 2-channel 
set-up accommodating a color channel and a fluorescence channel, the user can view the color 
image, the fluorescence image and the co-registered overlay image at the same time.  The 
technology has been successfully used in clinical trials (NCT01508572;  NCT02583568;  
NL45588;  NCT01972373;  NCT02129933;  NCT02113202) and a risk assessment used to 
receive respective IRB approvals is available on demand.  The technical specifications of the 
SurgVision Explorer Air (beta version) are as follows: 
Physical dimensions 
 
Height x Width x Length 
155 x 90 x 65 cm 
Weight 
90 kg 
Power 
 
Input Voltage 
240 V 50 Hz 
Power consumption 
Approx. 1500 W 
Optical Properties OR use 
 
Focal Length Lens 
16 mm 
F number 
1.6 
Working range 
15 to 50 cm 
Field of view  
15 cm 
Fluorescence excitation 
 
Wavelength 
760 nm 
Output power  
Max 2.6 W 
Visible light 
 
Luminous flux 
Approx. 1,100² 
Color temperature 
Approx. 5,600 K 
Fluorescence camera 
 
Active Pixels 
512 x 512 
Pixel Size 
16 x 16 µm 
Image Area 
8.2 x 8.2 mm 
Well Depth  
180,000 e- 
Max. Readout Rate 
17 MHz 
Frame Rate 
Max 56 fps 
Read Noise  
< 1 e- with EM gain 
QE max 
> 90% 
Cooling 
Water and/or forced ventilation water cooling unit 
included 
Color Camera 
 

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Resolution  
2046 x 2046 (H x V pixels) 
Pixel Size 
horizontal/vertical 
5.5 x 5.5 µm 
Frame Rate 
25 fps 
Mono/Color 
Color 
Sensor Size 
11.26 x 11.26 mm 
Image processing 
 
Operating system 
Microsoft Windows 
File format images 
Fits 
Camera Arm 
 
Arm extension 
1100 mm 
Height adjustment 
900 mm 
 
 
Figure Appendix 1.  Schematic drawing of the SurgVision Explorer Air (beta version) 

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Determination of Significant Risk or Non-Significant Risk  
The proposed SurgVision Explorer Air (beta version) is an investigational device. When 
evaluated as per 21 CFR § 812.3(m) - lnvestigational Device Exemptions, Definitions, the 
system does not present a potential for serious risk to the health, safety, or welfare of a subject. 
Specifically, 
 The device is not intended as an implant and does not present a potential for serious risk 
to the health, safety, or welfare of a subject. 
 The device is not purported or represented to be for a use in supporting or sustaining 
human life and does not present a potential for serious risk to the health, safety or welfare 
of a subject. 
 The device is not for a use of substantial importance in diagnosing, curing, mitigating, or 
treating disease, or otherwise preventing impairment of human health and does not 
present a potential for serious risk to the health, safety or welfare of a subject. 
 The device does not otherwise present a potential for serious risk to the health, safety or 
welfare of a subject. 
The investigational device is consequently classified as non-significant risk in the context of the 
proposed investigational studies and, under 21 CFR § 812.2(b), an investigational Device 
Exemption application is not required.  

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APPENDIX D: Photoacoustic imaging 
Rationale 
The use of molecular imaging has been shown to add relevant information to the surgeon in 
decision-making process during surgery and there is a need for non-ionizing imaging 
technologies that reliably visualize cancer with enhanced sensitivity and specificity.  The 
molecular imaging techniques that are suitable for intra-operative use are photoacoustic and 
fluorescence imaging.  The main advantage of photoacoustic imaging (PAI) is providing images 
at clinically relevant depths (5-7cm) with high spatial resolution (Zackrisson, van de Ven, et al.  
2014).  Which is essential for determination of the resection margin (> 1 cm) to be able to 
generate tumor-free margins.  Fluorescent imaging on the other hand is superior for imaging 
superficial lesions and vital structures (Vahrmeijer, Hutteman, et al.  2013).  
The principles of photoacoustics 
Alternative imaging techniques not involving ionizing radiation, e.g.  optical imaging, have 
emerged during the last decades.  Conventional optical imaging devices shine light on tissues.  
This light is both absorbed and scattered by the different tissue components.  NIR wavelength 
range of 600-1000 nm is used to obtain sufficient tissue penetration.  After passing through the 
tissue the remaining light is registered by detectors and an image can be reconstructed with the 
help of computer algorithms.  
In PAI, a pulsed nano-second laser beam illuminates the tissue sample and propagates diffusely 
inside the biological tissue.  When the light pulses are absorbed by certain light absorbing 
molecules (such as the hemoglobin in the blood vessels, melanin in skin, water) present inside 
the tissue, wide band ultrasound (photoacoustic) waves are generated due to transient 
thermoelastic expansion.  The waves are then detected by wide band ultrasonic transducer, 
Figure 3.  PAI can image tissue using endogenous contrast agents such as hemoglobin or 
exogenous contrast agents, such as ICG, and IRDye800.  Photoacoustic (PA) molecular imaging 
strategies using imaging agents targeting certain cancer biomarkers with high specificity and 
sensitivity can enhance and complement the functional imaging capabilities of the intrinsic 
signals (Gerling, Zhao, et al.  2014, Shao, Morgounova, et al.  2013).  
Imaging device 
PAI is an optical (non-ionizing) imaging technique that can provide high optical contrast images 
with the high spatial and temporal resolution of US.  It can in real-time simultaneously provide 
structural, functional and molecular information of tissues, provide information on tumor 
characteristics.  The technique has been evaluated in several phantom- and animal studies, and in 
a clinical pilot study in humans imaging the prostate with a hand held photoacoustic imaging 
system, Figure Appendix 1.  At this point, this technique is used in a clinical trial with prostate 
cancer patients (NCT01551576),  

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. 
B:  Bladder       P:  Prostate 
Figure Appendix 1:  (A-C) of Frame#1 and (D-F) of Frame#2 shows ultrasound, co-registered 
ultrasound and photoacoustic, and photoacoustic images of human prostate obtained with 
TRUSPA device.  Green circled area is prostate region and yellow circled region showing 
abnormal photoacoustic contrast in the prostate is due to the presence of prostate tumor in the 
right base close to the rectal wall. 
A hand held PAI instrument has been developed at Stanford (Kothapalli, et al, manuscript in 
preparation), Figure Appendix 2.  The probe integrates a fiber optic light guide and a state of art 
two-dimensional 16x16 element capacitive micromachined ultrasound transducer (CMUT) 
arrays with a center frequency of 5.5 MHz.  The PAI instrument has been tested in a deep tissue 
phantom model with optical absorbing objects of different absorption coefficients.  It was 
possible to demonstrate three-dimensional (3-D) photoacoustic imaging of light absorbing 
objects embedded as deep as 5 cm inside strong optically scattering phantoms.  In addition, the 
sensitivity of PAI to the concentration of indocyanine green (ICG) dye at 5cm depth inside the 
phantom was studied.  Under optimized experimental conditions, the objects at 5 cm depth could 
be imaged with SNR of about 35 dB and a spatial resolution of approximately 500 μm.  
Preliminary results of our group also showed a good photoacoustic signal with the dye IRDye800 
under experimental conditions. 
For these specific experiments, the laser wavelength was at 800 nm and the laser power was 15.4 
mJ/cm2.  This power is below the American National Standard for Safe Use of Lasers (ANSI) 
safety limit for human skin exposure of 20mJ/cm (Oraevsky AA, Ermilov, S, et al.  2006). 
The device is considered a low risk device and an Investigational Device Exemption (IDE) has 
been approved by the IRB at Stanford. 
 

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Figure Appendix 2.  Image showing the hand held photoacoustic probe.  IC and CMUT are 
flip-chip bonded and placed on PCB (printer circuit board).  PCB is rested in between two 
parallel fiber optic light guides that focus light 0.5 inch above the CMUT surface.  The entire 
PCB-light guide assembly is housed in acrylic probe that has similar dimensions as conventional 
ultrasound probe.  
Photoacoustic imaging in Cetuximab-IRDye800 trial 
Photoacoustic imaging will be done at the backtable in the imaging process.  That means during 
the optical imaging of tumor and waste tissue during pathological processing at the back-table 
and will not be used on subjects or in patient-care setting.  Once the tumor has been removed 
from the subject and sent to pathology, additional imaging will be performed on pathological 
specimens using the above described system.  This will be done in the frozen section in 
collaboration with the Department of Pathology to ensure preservation of tumor related 
information.  Normal waste tissues will also be imaged.  Resected tumor tissue sent for 
laboratory analysis will be analyzed according to current SOPs, using approved products as 
applicable.  Although this photoacoustic imaging device is not FDA approved, it will not be 
involved in direct subject contact or interfere with standard of care pathological 
processing.  Data from the research use of the device will not be used for diagnosis or other 
medical decision making. 
Availability 
Stanford University provides the PAI device.