Clinical trial NCT02509598
Conditions: Rhabdomyosarcoma Melanoma
Sponsor: Cardinal Health 414, LLC
Start date: 2015-08-01; Completion date: 2019-03-06
Enrollment: 24 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
Open label, non-randomized, multi-center, within-subject comparative study to evaluate the tolerability and the diagnostic utility of Lymphoseek with optional comparison to VBD in pediatric subjects with melanoma, rhabdomyosarcoma, or other solid tumor. Subject age will range from neonatal through 17 years.

Detailed description:

Arms: arm 1: 0.5 mCi, 50 ug of Tc99m tilmanocept single administration. Optionally, 1-3 mL of vital blue dye, single administration (per institution's standard of care).
Interventions: intervention 1: Tc99m tilmanocept intervention 2: Vital Blue Dye (optional) intervention 3: Lymph Node Mapping
Intervention descriptions: intervention 1: A single dose of 0.5 mCi and 50 ug of Tc99m tilmanocept administered intradermally, peritumorally approximately 15 minutes to 8 hours before surgery intervention 2: A single dose 1-3 mL of vital blue dye (1%) administered intradermally at the start of or during surgery (optional, per institution's standard of care). intervention 3: Intraoperative lymph node mapping will occur 15 minutes to 8 hours after Tc99m tilmanocept injection

Protocol documents:
Prot_SAP_000.pdf: 
NCT02509598


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SYNOPSIS 
Study title 
A 
Prospective, 
Open-Label, 
Multicenter 
Study 
of 
Lymphoseek® as a Lymphoid Tissue Targeting Agent in 
Pediatric Patients With Melanoma, Rhabdomyosarcoma, or 
Other Solid Tumors Who Are Undergoing Lymph Node 
Mapping 
Study phase 
Phase 2 
Study objective(s) 
Primary: To evaluate safety and tolerability of Lymphoseek 
in pediatric subjects with melanoma, rhabdomyosarcoma, or 
other solid tumors who are undergoing lymph node mapping. 
Secondary: 
•
To assess the identified lymph node(s) to confirm: the
presence/absence of tumor metastases; agent localization
per tumor type; degree of localization (nodes per subject
both intraoperatively and with preoperative SPECT).
•
To determine the concordance of in vivo localization
rates of Lymphoseek and LymphazurinTM, a vital blue
dye (VBD), in tissue excised and histologically
confirmed as lymph nodes from those subjects receiving
two mapping agents.
•
To record the change of subject stage based on
histopathology and make a descriptive assessment on
change in treatment plan
Study drug 
Lymphoseek® 
Dose(s) 50 µg Lymphoseek radiolabeled with 18.5 MBq (0.5 mCi) 
99mTc 
Route of administration For subjects with melanoma, Lymphoseek will be 
administered as 1, 2 or 4 intradermal, peritumoral injections 
or around 
the 
excision 
biopsy 
site. 
For 
subjects 
with rhabdomyosarcoma or other solid tumor type, 
Lymphoseek 
will 
be 
administered 
as 
intradermal 
peritumoral injection(s) if anatomically appropriate or, if 
not possible, injection should be performed as determined 
clinically appropriate by the surgeon. 
Duration of treatment Single administration 
Control (optional) 
Lymphazurin (1% isosulfan blue for injection), a VBD, 
administered by subcutaneous injection immediately before 
or during the surgical procedure, per the agent labeling.  Use 
of Lymphazurin is optional, consistent with institutional 
practice. 


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US Indication 
 
 
 
 
 
 
Lymphoseek is a radioactive diagnostic agent indicated with 
or without scintigraphic imaging for: 
• Lymphatic mapping using a handheld gamma counter to 
locate lymph nodes draining a primary tumor site in 
subjects with solid tumors for which this procedure is a 
component of intraoperative management. 
• Guiding sentinel lymph node biopsy using a handheld 
gamma counter in subjects with clinically node negative 
squamous cell carcinoma of the oral cavity, breast 
cancer, or melanoma. 
Main criteria for inclusion 
1. The subject's parent(s)/legal guardian(s) understand(s) 
and voluntarily signed an informed consent document 
prior to any study-related assessments/procedures being 
conducted. Where locally applicable, the subject also 
understands and voluntarily provides his/her assent prior 
to any study-related assessments/procedures being 
conducted. 
2. Subject 
has 
been 
diagnosed 
with 
melanoma, 
rhabdomyosarcoma, or other solid tumors where tumor 
resection or biopsy is planned and lymph node mapping 
is appropriate.  
3. The subject is clinically node negative (cN0) at the time 
of screening. 
4. Age < 18 years  
5. Male subjects of childbearing potential must be willing 
to use a condom during sexual intercourse and shall not 
father a child during the course of the study or will 
practice complete abstinence while on study. 
6. Female subjects of childbearing potential must agree to 
the use of two physician-approved contraceptive methods 
simultaneously or practice complete abstinence while on 
study. 
Main criteria for exclusion 
1. The subject has had preoperative radiation therapy.  
2. Has had previous surgery or radiation to node basins that 
would be involved in the intraoperative lymph node 
mapping (ILM) procedure. 
3. Has a known allergy to dextran, or VBD (if intended to 
be used). 
4. Has a history of alcohol abuse or alcohol dependency in 
the 3 years before study entry, or is an alcoholic or drug 
addict, as determined by the investigator. 
5. Before the administration of Lymphoseek, has received 
any radiopharmaceutical within 7 radioactive half-lives 
of that radiopharmaceutical. 
 


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Study design 
Prospective, open label, non-randomized, multicenter, 
blinded pathology assessment study to evaluate the 
tolerability and the diagnostic utility of Lymphoseek in 
pediatric subjects with melanoma, rhabdomyosarcoma, or 
other solid tumors. Subject age will range from neonatal 
through 17 years. If consistent with institutional practice, 
subjects may also receive Lymphazurin for a within-subject 
comparison of lymph node mapping. 
Methodology 
The proposed study includes 3 visits: A screening visit for 
initial determination of eligibility and evaluation of clinical 
status, a baseline visit on the day of surgery, and a 4- to 
14-day (in person) safety follow-up to assess subject disease 
management.  
Screening Visit (Day -29 to 0):  
The screening visit will include review of trial eligibility, 
demography, performance status, cancer staging, informed 
consent, collection of medical history, vital signs, physical 
exams, electrocardiogram (ECG), review of medications, and 
clinical laboratory evaluation.  A urine or serum pregnancy 
test will be performed for female subjects of childbearing 
potential within 48 hours prior to injection. 
Baseline Visit (Day 1): 
All subjects will receive a single dose of 50 µg Lymphoseek 
radiolabeled with 18.5 MBq (0.5 mCi) 99mTc (in a volume of 
up to 1.0 mL) at least 15 minutes but no more than 8 hours 
before the start of the surgical procedure. 
For subjects with melanoma, Lymphoseek will be 
administered as 1 to 4 intradermal, peritumoral injections or 
around the excision biopsy site. For subjects with 
rhabdomyosarcoma or other solid tumor type, Lymphoseek 
will be administered as intradermal peritumoral injection(s) 
if anatomically appropriate or, if not possible, injection 
should be performed as determined clinically appropriate by 
the surgeon. Radioactive dose, volume, injection site(s), 
route, and syringe type will be documented. 
An ECG will be recorded on Day 1 at least 10 minutes after 
Lymphoseek injection. Vital signs will be recorded at 
prespecified intervals before and after Lymphoseek 
administration.  
After safety measurements have been completed and before 
surgery, subjects may undergo dynamic and/or planar 
SPECT or SPECT/CT lymphoscintigraphy according to 


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institutional imaging protocols. Imaging should begin at the 
time of injection when performing dynamic imaging. 
STATIC planar imaging should begin approximately 15 
minutes post injection.  
At least 15 minutes and no more than 8 hours after 
Lymphoseek injection, subjects will undergo surgery to 
remove the primary tumor and all lymph nodes detected 
during the lymphatic mapping procedure. If in agreement 
with institutional practice, Lymphazurin will be administered 
in the operating room immediately before or during surgery.  
The injection of Lymphazurin will only be performed as 
deemed appropriate by the surgeon and in accordance with 
the standard of care at the clinical site. Blood and urine 
samples will be collected for safety laboratory analyses post-
surgery. 
Safety follow-up (Day 4 to 14): Vital sign assessment, 
physical examination, and review of medications will be 
performed between 4 to 14 days after Lymphoseek injection. 
Postsurgical treatment plan; tumor, lymph node, metastasis 
(TNM) staging; and clinical group will be collected.  
Adverse events (AE) will be monitored at each visit, starting 
with the Baseline visit. 
Planned trial dates 
Start of study  August 
2015 
End of Study 
June 2021 
Planned number of trial 
centers / countries 
Up to 10 sites in the United States 
Number of subjects 
For the primary analysis of safety, at least 27 subjects 
administered Lymphoseek will be evaluated: 
• At least 6 subjects with melanoma 
• At least 6 subjects with rhabdomyosarcoma 
Enrollment will be open to up to 15 additional subjects with 
other tumor types in which ILM and sentinel lymph node 
biopsy (SLNB) are appropriate. 
At least 20 of the recruited subjects will be ≤16 years of age. 
Safety endpoints 
Primary 
 
Secondary 
 
Incidence of AEs  
 
Changes over time in vitals signs, laboratory tests, and ECGs 
Diagnostic endpoints 
• Proportion of subjects with Lymphoseek-identified 
lymph nodes (i.e., localization) 


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• Number of Lymphoseek-identified lymph nodes per 
subject (i.e., degree of localization) 
• Proportion of subjects who underwent preoperative 
SPECT lymphoscintigraphy 
• Comparison of the number of lymph nodes detected with 
Lymphoseek intraoperatively to the number of nodes 
detected with preoperative SPECT 
• Comparison 
of 
centralized, 
blinded 
pathologic 
assessment to local pathologic assessment of the excised 
lymph node(s) to confirm the presence/absence of tumor 
metastases on a per-subject and per-node basis 
• False negative rates and sensitivity for each detection 
method in subjects undergoing lymphadenectomy 
• Upstaging 
• Change in nodal staging before and after surgery based 
upon Lymphoseek-identified nodes (and Lymphazurin, if 
applicable) 
• Number of changes in treatment plan and relation to 
lymph nodes identified by Lymphoseek  
 
Additionally for those subjects receiving both Lymphoseek 
and Lymphazurin: 
• Proportion of subjects with Lymphazurin-identified 
lymph nodes (i.e., localization) 
• Number of Lymphazurin-identified lymph nodes per 
subject (i.e., degree of localization) 
• Proportion of lymph nodes (and subjects) identified 
intraoperatively by Lymphazurin that are also identified 
intraoperatively by Lymphoseek (i.e., nodal and per-
subject concordance) 
• Proportion of lymph nodes identified intraoperatively by 
Lymphoseek that are also identified intraoperatively by 
Lymphazurin control (i.e., nodal and per-subject reverse 
concordance) 
• Difference between nodal and reverse nodal concordance  
 
Plan for statistical analysis 
Analysis populations: 
• Safety: all enrolled subjects with administration of 
Lymphoseek 
• Intent-to-treat 
(ITT): 
all 
enrolled 
subjects 
with 
administration 
of 
Lymphoseek 
(with 
or 
without 


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Lymphazurin) and complete intraoperative lymphatic 
mapping 
• Blue intent-to-treat (BITT): all ITT subjects with 
administration of Lymphazurin prior to ILM 
• Per protocol (PP): all ITT subjects without major 
protocol violations 
All safety analyses will be conducted on the safety 
population. The analysis of the diagnostic endpoints will be 
conducted on ITT, BITT, and PP populations, as applicable. 
AEs will be summarized using system organ class and 
preferred term by tumor type and overall for all subjects in 
the safety population. AEs will also be summarized by 
severity, relationship to investigational product, and 
relationship to study procedure. All AEs will be listed. 
Summary statistics (mean, median, sample size, standard 
deviation, minimum, and maximum) will be computed on 
the raw and change from baseline values for each vital sign 
parameter, quantitative laboratory parameter, and ECG 
parameter by time point, for each tumor type and overall. 
The localization rate, degree of localization, difference in 
preoperative SPECT versus intraoperative localization, 
agreement proportions of central pathology assessment to 
local pathology assessment, false negative rates, sensitivity 
rates, and upstaging, along with 95% confidence intervals, 
will be computed for each tracer (as applicable) for each 
tumor type and overall. 
The proportion of ITT subjects with preoperative SPECT 
performed, those who had a hot spot on scan, and the time 
from Lymphoseek injection to hot spot localization, will be 
summarized by tumor type and overall. 
Changes in nodal staging will be assessed via shift tables. 
Changes in treatment plan and relation to lymph nodes will 
be listed. 
Concordance endpoint analysis: For the BITT population, 
the number and proportion of concordant lymph nodes 
(Lymphoseek to Lymphazurin) will be computed, and a 
statistical test to determine if the concordance rate is greater 
than 0.9 will be conducted. In order for the test of the nodal 
concordance endpoint to successfully reject the null 
hypothesis that the concordance rate is ≤0.9, the lower 
boundary of the one-sided 95% exact binomial confidence 


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interval must exceed 0.9 in the BITT population. In-house 
and/or literature data indicating that nodes may be 
considered as an independent sample will supplement the 
analysis.  
If the test of the concordance endpoint is met (i.e., the null 
hypothesis is rejected), then a test for superiority of 
concordance relative to the secondary diagnostic endpoint of 
reverse concordance will be conducted using McNemar’s 
test. If the one-sided p-value of the test is <0.05, then the 
concordance rate of Lymphoseek to Lymphazurin will be 
shown to be significantly greater than the reverse 
concordance rate of Lymphazurin to Lymphoseek. 
The per-subject concordance and per-subject reverse 
concordance will also be computed along with 95% 
confidence intervals using the BITT population. 
No formal interim analyses will be conducted during this 
study. 
Data listings and tables will be created on an interim basis 
for review by a Data and Safety Monitoring Committee 
(DSMC), which is further described in Section 9.11.   


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TABLE OF CONTENTS 
SYNOPSIS .................................................................................................................................2 
LIST OF IN-TEXT TABLES ..................................................................................................13 
LIST OF APPENDICES ..........................................................................................................13 
LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS ..........................................14 
TRIAL ADMINISTRATIVE STRUCTURE ..........................................................................16 
LABORATORIES AND OTHER INSTITUTIONS FOR TRIAL CONDUCT .....................16 
1 
INTRODUCTION ...........................................................................................................17 
1.1 
Background ............................................................................................................17 
1.2 
Previous Nonclinical Research and Clinical Trial Experience with 
Tilmanocept and Lymphoseek ...............................................................................20 
1.2.1 
Nonclinical Evaluations ...............................................................................20 
1.2.2 
Clinical Pharmacokinetics and Pharmacodynamics ....................................21 
1.2.3 
Clinical Efficacy ..........................................................................................21 
1.2.4 
Clinical Safety ..............................................................................................22 
1.2.5 
Radiation Exposure (Subjects) .....................................................................22 
1.2.6 
Radiation Exposure (Health Care Workers and Care Givers) .....................22 
2 
STUDY OBJECTIVES ....................................................................................................24 
2.1 
Primary Objective ..................................................................................................24 
2.2 
Secondary Objectives.............................................................................................24 
3 
OVERVIEW OF METHODOLOGY AND DESIGN .....................................................25 
3.1 
Overall Study Design .............................................................................................25 
3.2 
Justification for Study Design and Population.......................................................25 
3.2.1 
Parent/Guardian ...........................................................................................26 
3.2.2 
Rationale for Subject Selection ....................................................................26 
3.2.3 
Justification for Radiation Exposure With Proposed Lymphoseek 
Radioactive Dose .........................................................................................26 
3.3 
Protocol Adherence ................................................................................................26 
3.4 
Study Duration .......................................................................................................27 
4 
STUDY POPULATION ..................................................................................................28 
4.1 
Eligibility ...............................................................................................................28 
4.1.1 
Inclusion Criteria .........................................................................................28 
4.1.2 
Exclusion Criteria ........................................................................................28 
4.1.3 
Justification of Selection Criteria.................................................................28 
4.2 
Recruitment ............................................................................................................29 
4.3 
Withdrawal .............................................................................................................29 
4.4 
Replacement ...........................................................................................................30 


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4.5 
Subject Identification .............................................................................................30 
5 
INVESTIGATIONAL PRODUCT ..................................................................................31 
5.1 
Identification of Investigational Product ...............................................................31 
5.2 
Investigational Product Dosage and Administration .............................................31 
5.3 
Vital Blue Dye .......................................................................................................31 
5.4 
Treatment Assignment ...........................................................................................31 
5.5 
Packaging and Labeling .........................................................................................31 
5.6 
Drug Logistics and Accountability ........................................................................32 
6 
THERAPIES OTHER THAN INVESTIGATIONAL PRODUCT .................................33 
6.1 
Prior and Concomitant Therapy .............................................................................33 
6.2 
Post-Study Therapy ................................................................................................33 
7 
SCHEDULE OF EVALUATIONS AND VISIT DESCRIPTION .................................34 
7.1 
Schedule of Evaluations .........................................................................................34 
7.2 
Visit Description ....................................................................................................34 
7.2.1 
Screening Visit (Day -29 to Day 0) .............................................................34 
7.2.2 
Before Enrollment ........................................................................................35 
7.2.3 
Preparation of Lymphoseek .........................................................................35 
7.2.4 
Day 1: Before Injection ................................................................................35 
7.2.5 
Day 1: Injection of Lymphoseek..................................................................35 
7.2.6 
Day 1: Post Injection ....................................................................................35 
7.2.7 
Day 1: Imaging and Surgery ........................................................................36 
7.2.8 
Day 1: After Surgery ....................................................................................36 
7.2.9 
Day 4 to 14: Postsurgical Safety Follow-up ................................................36 
7.2.10 
End of Study ................................................................................................36 
8 
PROCEDURES AND VARIABLES ..............................................................................37 
8.1 
Population Characteristics .....................................................................................37 
8.1.1 
Demographic and Other Baseline Characteristics .......................................37 
8.1.2 
Medical and Surgical History ......................................................................37 
8.1.3 
Staging .........................................................................................................37 
8.1.4 
Performance Status ......................................................................................43 
8.1.5 
Prior and Concomitant Medication ..............................................................44 
8.2 
Lymphoseek Preparation and Injection .................................................................44 
8.3 
SPECT/SPECT-CT or Other Gamma Image Acquisition and Image Transfer .....44 
8.4 
Surgical Procedures, Lymphatic Mapping, and Lymph Node Biopsy ..................45 
8.4.1 
Lymphoseek-Designated “Hot” Nodes ........................................................45 
8.4.2 
Surgical Lymph Node Identification ...........................................................46 
8.5 
Histopathology of Lymph Nodes ...........................................................................47 
8.5.1 
Local Lymph Node Evaluation ....................................................................47 


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8.5.2 
Preparation and Shipping of Lymph Node Samples to Central 
Laboratory ....................................................................................................48 
8.5.3 
Central Laboratory Processing of Samples ..................................................48 
8.6 
Pharmacokinetics ...................................................................................................48 
8.7 
Safety .....................................................................................................................49 
8.7.1 
Adverse Events ............................................................................................49 
8.7.1.1 
Definition of Adverse Event ..............................................................49 
8.7.1.2 
Categories for Adverse Event Assessment ........................................49 
8.7.1.3 
Assessments and Documentation of Adverse Events ........................51 
8.7.1.4 
Expected Adverse Events ..................................................................51 
8.7.1.5 
Serious Adverse Events .....................................................................53 
8.7.2 
Further Safety Assessments .........................................................................54 
8.7.2.1 
Physical Examination.........................................................................54 
8.7.2.2 
Vital Signs ..........................................................................................55 
8.7.2.3 
Electrocardiogram ..............................................................................55 
8.8 
Other Procedures and Variables.............................................................................55 
8.8.1 
Blood Sampling ...........................................................................................55 
8.8.2 
Laboratory Data Related to Screening and Safety .......................................55 
9 
STATISTICAL METHODS ............................................................................................58 
9.1 
Introduction ............................................................................................................58 
9.2 
Randomization Methods ........................................................................................58 
9.3 
Pooling of Study Centers .......................................................................................58 
9.4 
Safety Variables .....................................................................................................58 
9.4.1 
Primary Safety Variable ...............................................................................58 
9.4.2 
Secondary Safety Variables .........................................................................58 
9.5 
Pharmacokinetic Variables ....................................................................................58 
9.6 
Diagnostic Variables ..............................................................................................58 
9.6.1 
Primary Diagnostic Variables ......................................................................58 
9.6.2 
Secondary Diagnostic Variables ..................................................................59 
9.7 
Sample Size Justification .......................................................................................60 
9.8 
Handling of Missing Data ......................................................................................60 
9.9 
Statistical Analysis .................................................................................................60 
9.9.1 
Analysis Populations ....................................................................................60 
9.9.2 
Analysis of Baseline and Demographic Characteristics ..............................61 
9.9.3 
Analysis of Primary Safety Variables ..........................................................61 
9.9.4 
Analysis of Secondary Safety Variables ......................................................61 
9.9.5 
Analysis of Primary Diagnostic Variables ...................................................61 
9.9.6 
Analysis of Secondary Diagnostic Variables ...............................................63 
9.10 
Interim Analyses ....................................................................................................65 


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9.11 
Data and Safety Monitoring Committee ................................................................65 
10 DATA HANDLING AND QUALITY ASSURANCE ...................................................66 
10.1 
Data Recording ......................................................................................................66 
10.1.1 
Electronic CRF design .................................................................................66 
10.2 
Monitoring .............................................................................................................66 
10.3 
Data Processing ......................................................................................................66 
10.4 
Auditing .................................................................................................................67 
10.5 
Archiving ...............................................................................................................67 
10.6 
Premature Termination of the Study ......................................................................67 
10.6.1 
Study as a Whole .........................................................................................68 
10.6.2 
Study Participant ..........................................................................................68 
11 ETHICAL AND LEGAL ASPECTS...............................................................................69 
11.1 
Ethical and Legal Conduct of the Study ................................................................69 
11.2 
Subject Information and Consent...........................................................................69 
11.3 
Financing/Financial Disclosure .............................................................................70 
11.4 
Publication Policy ..................................................................................................70 
11.5 
Subject Injury .........................................................................................................70 
12 REFERENCE LIST .........................................................................................................71 
 


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LIST OF IN-TEXT TABLES 
Table 1.  
Estimated Radiation Absorbed Dose for a 0.5 mCi, 50 µg Dose of 
Lymphoseek in Intradermal Injection of Cancer Patients  (Reference 
Patient is Intradermal Injection of Lymphoseek; Units in mGy) ................23 
Table 2.   
Minimum enrollment per age group ............................................................29 
Table 3. 
Rhabdomyosarcoma TNM Classification ....................................................38 
Table 4. 
Rhabdomyosarcoma Staging .......................................................................39 
Table 5. 
Clinical Group Rhabdomyosarcoma ............................................................40 
Table 6. 
Melanoma TNM Classification....................................................................41 
Table 7. 
Melanoma Staging .......................................................................................42 
Table 8.   
Performance Status Scale .............................................................................43 
Table 9.   
Handling of Excised Tissue .........................................................................47 
Table 10. 
Minimum Clinical Laboratory Parameters ..................................................56 
Table 11. 
Amount of Blood Withdrawn ......................................................................57 
 
LIST OF APPENDICES 
Appendix 1 Schedule of Events .......................................................................................77 
Appendix 2 Gamma Detector Counts Calculation Sheet ................................................78 
Appendix 3 Sponsor’s Signatures ....................................................................................79 
Appendix 4 Investigator’s Signature ...............................................................................80 
 
 


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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
adverse event 
ADR 
adverse drug reaction 
AJCC 
American Joint Committee on Cancer 
ALARA 
as low as reasonably achievable 
BITT 
blue intent-to-treat 
°C 
degrees Celsius 
CD206 
the mannose binding receptor 
cm 
centimeters (10-2 m) 
CRA 
clinical research associate 
CRF 
case report form 
CRO 
contract research organization 
DICOM 
Digital Imaging and Communications in Medicine 
DSMC 
Data and Safety Monitoring Committee 
DTPA 
diethylenetriaminepentaacetic acid 
ECG 
electrocardiogram 
EDE 
effective dose equivalent 
°F 
degrees Fahrenheit 
FNR 
false negative rate 
GCP 
Good Clinical Practices 
H&E 
hematoxylin and eosin 
ICH 
International Conference on Harmonization 
HNSCC 
with head and neck squamous cell cancer  
%IDSN 
percent of injected dose in the sentinel node(s) 
IHC 
immunohistochemical 
ILM 
intraoperative lymphatic mapping 
IRB 
Institutional Review Board 
ISF 
investigator site file 
ITT 
intent-to-treat 
keV 
kiloelectron-volt 
LN 
lymph node 
Lymphoseek 
technetium Tc 99m tilmanocept 
mCi 
millicurie (10-3 Ci; 3.7x107 Becquerel or Bq) 
MedDRA 
Medical Dictionary for Regulatory Activities 
MBq 
Megabecquerel 
µg 
micrograms (10-6 g) 
mGy 
Milligray 
mL 
milliliters (10-3 L) 
mm 
millimeters (10-3 m) 
mmHg 
millimeters of mercury 
MRI 
magnetic resonance imaging 
µSv 
Microsievert 


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µm 
micrometers (10-6m) 
nm 
nanometers (10-9 m) 
NOAEL 
no observed adverse effect level 
OLINDA 
Organ Level Internal Dose Assessment 
PP 
per protocol 
QC 
quality control 
RBC 
red blood cell 
σ 
sigma; standard deviation 
SAE 
serious adverse event 
SCC 
squamous cell carcinoma 
SLN 
sentinel lymph node 
SLNB 
sentinel lymph node biopsy 
SPECT/CT 
single photon emission computed tomography/computed 
tomography 
Sponsor 
Cardinal Health 414, LLC (Cardinal) 
SUSAR 
Suspected, Unexpected, Serious Adverse Reaction 
99mTc 
technetium-99m metastable isotope; γ-emitting (t½ = 6.02 h) 
Tilmanocept 
DTPA Mannosyl Dextran (the US Adopted Name for the drug 
substance of Lymphoseek) 
TMF 
trial master file 
TNM 
tumor, lymph node, metastasis staging 
US 
United States 
FDA 
Food and Drug Administration 
VBD 
vital blue dye; LymphazurinTM as 1% isosulfan blue for injection; 
USFDA-approved ILM colorimetric agent 
 




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1 
INTRODUCTION 
1.1 
Background 
Intraoperative Lymphatic Mapping (ILM) and Sentinel Lymph Node Biopsy (SLNB) in 
Adult Cancer Patients 
In patients with malignant melanoma and breast cancer, lymph node status is often a strong 
predictor of outcome and influences the course of treatment a patient may follow after 
surgery. In an effort to reduce the morbidity and cost of detecting lymph node metastases, 
surgical oncologists have developed a method by which the sentinel lymph node(s) (SLN); 
i.e., the first node or nodes in a draining basin), which have the highest probability of 
harboring cancer, is/are identified intraoperatively and removed. This technique, called ILM 
with SLNB, has extremely high negative predictive values for both melanoma (Morton et al., 
2006) and breast cancer (Giuliano et al., 1994) metastases. The two largest trials for 
melanoma (Morton et al., 2005 and Rossi et al., 2006), reported false negative rates of 6.3% 
and 14.7%, respectively. Morton et al. (2006) showed a false negative rate of 3.4%.  SLNB 
has also been evaluated with positive results in adult patients being surgically treated for 
head and neck squamous cell carcinoma (Thompson et al., 2012; Stoeckli, 2007; Melkane et 
al., 2012; Broglie et al., 2011; Marcinow et al., 2013), colon cancer (Dionigi et al., 2007; van 
der Zaag et al., 2012), prostate cancer (Ponholzer et al., 2012), cervical cancer (Gortzak-
Uzan et al., 2010; Bats et al., 2012), and lung cancer (Taghizadeh et al., 2013). 
During an ILM procedure with SLNB, a radioactive tracing agent such as Lymphoseek, is 
injected at the site of the primary tumor and follows the drainage path of the tumor to the 
nearest lymph node(s). After injection of the radioactive agent, external scintigraphic 
imaging (i.e., lymphoscintigraphy or preoperative single photon emission computed 
tomography [SPECT]) can be performed to assist in the preoperative localization of nodes. A 
handheld gamma detection device is then used to track the pathway of the tracing agent. 
Lymph nodes in the potential drainage pathway are identified using the radioactive tracing 
agent. 
Lymphoscintigraphy and intraoperative mapping with a handheld gamma detection device 
are relatively noninvasive techniques for mapping the lymphatic drainage patterns to track 
whether cancer cells have metastasized from the primary tumor to the local lymph nodes. 
Once a specific area of lymph drainage has been identified by the tracer, the SLN(s) can be 
removed surgically and tested in the pathology laboratory. Lymphatic mapping with 
Lymphoseek allows prompt visualization of the lymphatic system, produces high-quality 
images, and delivers a low radiation dose to the patient. In addition, good regional lymph 
node retention is seen with Lymposeek, thus improving the success rate of intraoperative 
gamma probe localization. In combination with surgical localization, lymphoscintigraphy 
allows preoperative and intraoperative identification of the SLNs in patients with breast 
cancer and  melanoma, obviating the need for radical lymph node dissection in most patients 
and possibly prolonging their survival.  


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ILM and SLNB in Pediatric Rhabdomyosarcoma and Melanoma Patients 
Rhabdomyosarcoma: Rhabdomyosarcoma is a malignancy derived from muscles that are 
attached to the bones (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002402/). It occurs 
most commonly on the structures of the head and neck, the urogenital tract, and the arms or 
legs. Rhabdomyosarcoma occurs predominately in children and is the most common soft 
tissue tumor in children under 18 years of age (Arndt and Crist, 1999). Roughly two-thirds of 
cases occur in patients between the ages of 1 and 10. According to the American Cancer 
Society (2014), about 350 cases of rhabdomyosarcoma are newly diagnosed each year in the 
United States. Because rhabdomyosarcomas are complex cancers and because radiation and 
chemotherapy 
treatments 
can 
have 
long-term 
consequences, 
patients 
with 
rhabdomyosarcomas are usually treated at centers with significant experience in treating this 
type of cancer (Gosiengfiao et al., 2012; Walterhouse and Watson, 2007). Most 
rhabdomyosarcomas can be classified into one of two histological or pathophysiological 
subtypes: embryonal rhabdomyosarcoma (Li et al., 2013) or alveolar rhabdomyosarcoma 
(Nordberg et al., 2012; Tuna et al., 2012). These subtypes differ in their prognoses, optimal 
treatments, and various genetic and gene expression alterations. For either type, accurate 
disease staging including lymph node status relative to the spread of the cancer is a key 
prognostic variable and an important determinant of post-surgical therapies (Rodeberg  et al., 
2011; Baker et al., 2000; Bisogno et al., 2012; Blakely et al., 2003; La et al., 2011; Wharam 
et al., 2004; Leaphart and Rodeberg, 2007). 
Despite the well-established importance of accurate disease staging and removal of nodal 
metastases in rhabdomyosarcoma patients and the established safety and efficacy of ILM and 
SLNB in adult cancer patients, there have been few studies of ILM and SLNB in pediatric 
rhabdomyosarcoma patients. In seven studies published since 2000 (Neville et al., 2000; 
McMulkin et al., 2003; Gow et al., 2008; Kayton et al., 2008, Weiss et al., 2011; De Corti et 
al., 2009; Parida et al., 2012), ILM and SLNB procedures were performed in 28 pediatric 
rhabdomyosarcoma patients.  Positive nodes were identified in 6 of the 28 patients (21.4%). 
These studies demonstrated that these procedures were technically feasible and were not 
associated with complications.  
The limited clinical experience of ILM and SLNB in pediatric rhabdomyosarcoma patients 
can be contrasted with the experience related to regional lymph node dissections in this same 
population of patients. As far back as 1987, Lawrence et al. reviewed medical records of 592 
children who were surgically treated for rhabdomyosarcoma, identifying 81 (14%) with 
histologically proven metastases to regional lymph nodes. This study showed that lymph 
node metastases were highly associated (p = 0.001) with poorer survival. In 2004, the 
Intergroup Rhabdomyosarcoma Study reported on the outcomes of 405 children treated for 
rhabdomyosarcomas (Wharam et al., 2004).  This study found that “Lymph node 
involvement at diagnosis was the single factor most predictive of increased total local failure 
risk…” More recently (La et al., 2011), an evaluation of 226 children being treated for 
rhabdomyosarcomas of the extremities was performed with 55 (24%) having been found to 
have lymph node metastases. It was concluded that evaluation of lymph nodes was necessary 
for disease staging and optimal treatment. These findings are examples of a much wider 
literature showing the importance of lymph node evaluations in rhabdomyosarcoma patients; 


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the published clinical experience with regional lymph node dissections in this patient 
population extends to well over a thousand patients.  In adult cancer patients, ILM and SLNB 
have been evaluated in many thousands of patients and have been found to be safe and 
effective alternatives to regional lymph node dissections, allowing for less surgery-related 
trauma and a lower incidence of post-surgical lymphedema.  
Melanoma: Melanomas in children are relatively rare, occurring at about the same rate as 
rhabdomyosarcomas (Mills and Messina, 2009; Lange et al., 2007; Lewis, 2008), although 
the reported incidence of pediatric melanoma appears to be rising (Linabery and Ross, 2008; 
Downard et al., 2007; Strouse et al., 2005).  Girls are more likely than boys to be diagnosed 
with melanomas (Berk et al., 2010). 
Compared with the experience in rhabdomyosarcoma patients, ILM and SLNB have been 
extensively evaluated in pediatric patients with melanomas. A review of the literature on the 
use of ILM and SLNB in pediatric melanoma patients (Neville et al., 2000; Gow et al., 2008; 
De Corti et al., 2009; Berk et al., 2010; Zuckerman et al., 2001; Toro et al., 2003; Pacella et 
al., 2003; Butter et al., 2005; Roaten et al., 2005; Shah et al., 2006; Livestro et al., 2007; 
Topar and Zelgar, 2007; Howman-Giles et al., 2010; Moore-Olufemi et al., 2011) yielded the 
following conclusions: 
• Pediatric melanoma patients are more likely to have positive SLNs than adult melanoma 
patients and young children more so than adolescents, i.e., age is inversely proportional 
to SLN positivity. 
• ILM and SLNB are safe and effective alternatives to regional lymph node dissections and 
can be used similarly to ILM and SLNB use in adult melanoma patients. 
• SLNB provides information that can guide post-surgical treatment decisions. 
Due to the success of ILM and SLNB in pediatric melanoma cases and the acceptance of 
these procedures as the standard of care in adult melanoma patients, most children 
undergoing surgeries to remove melanomas have these procedures, even though ILM agents 
have not been approved by the Food and Drug Administration (FDA) for use in children. 
(Raval et al. 2010) reviewed pediatric melanoma cases from the National Cancer Data Base 
in which 461 of 671 (68.7%) children in the database who were treated for melanoma 
between 2003 and 2007 had SLNBs; 25.6% of the patients undergoing SLNB had pathology-
confirmed lymph node metastases. 
Vital Blue Dye (VBD) 
Lymphazurin (1% isosulfan blue for injection) is a sterile aqueous solution for subcutaneous 
administration. Lymphazurin is used for visualization of the lymphatic system draining the 
region of injection. Lymphazurin and other VBDs depend solely on their inherent color in 
order to provide visualization of the lymphatic structures, effectively requiring line-of-sight 
as the method of feedback to the surgeon. This requires the surgeon to hunt, via dissection of 
the tissue between the injection site and any flow-to point, in order to acquire the line-of-
sight as these agents have no particular specificity for localization in the tissues of interest. 
VBD’s reliability as a singly applied ILM agent has come under question in the literature 


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(Neves et al., 2010; Montgomery et al., 2002; Gur et al., 2011; Aydogan et al., 2008; Kang et 
al., 2010). 
Lymphoseek 
Lymphoseek is a radiotracer that accumulates in lymphatic tissue by binding to a mannose 
binding receptor that resides on the surface of dendritic cells and macrophages within the 
nodes. Lymphoseek is a macromolecule consisting of multiple units of DTPA 
(diethylenetriaminepentaacetic acid) and mannose, each synthetically attached to a 
10 kilodalton dextran backbone. The mannose acts as a substrate for the receptor and the 
DTPA serves as a chelating agent for labeling with 99mTc. Standard lymphosintigraphy has 
been performed using 99mTc sulfur colloid particles (50 to 800 nm in size) that are 
nonselectively removed by lymph node phagocytosis. Lymphoseek has a diameter of about 
7 nm (Vera et al., 2001), which is substantially smaller than current radiolabeled agents used 
for targeting lymphoid tissue. Lymphoseek's small diameter permits enhanced diffusion into 
lymph nodes and blood capillaries, resulting in a rapid injection site clearance. Lymphoseek 
has demonstrated less injection pain perception by patients (Unkart et al., 2015), faster 
injection site transit, more successful localization of lymph nodes, and detection of more 
lymph nodes in the lymphatic drainage pathways in subsets of patients receiving 
Lymphoseek compared with other subsets having sulfur colloid (Ellner et al., 2003; Wallace 
et al., 2007a; Wallace et al., 2007b; Wallace et al., 2003; Wallace et al., 2009). 
Lymphoseek is approved by the US (United States) Food and Drug Administration for use in 
lymphatic mapping to assist in the localization of lymph nodes draining a primary tumor site 
in patients with solid tumors for which this procedure is a component of intraoperative 
management and for guiding SLNB in patients with clinically node negative squamous cell 
carcinoma (SCC) of the oral cavity, breast cancer, or melanoma. 
Lymphoseek is approved in the European Union (EU) for use in imaging and intraoperative 
detection of sentinel lymph nodes draining a primary tumor in adult patients with breast 
cancer, melanoma, or localized squamous cell carcinoma of the oral cavity. 
1.2 
Previous Nonclinical Research and Clinical Trial Experience with 
Tilmanocept and Lymphoseek 
A detailed evaluation of safety and efficacy data from nonclinical and clinical studies can be 
found in the accompanying Investigator’s Brochure supplied by Cardinal.  In addition, the 
data described in this protocol are reported in peer-reviewed publications, including 
nonclinical studies (Hoh et al., 2003), the Phase 1 clinical trials (Ellner et al., 2003; Wallace 
et al., 2007a; Wallace et al., 2007b; Wallace et al., 2003; Wallace et al., 2009), the Phase 2 
clinical trial (Leong et al., 2011) and the Phase 3 studies (Tokin et al., 2012; Sondak et al., 
2012; Wallace et al., 2013; Marcinow et al., 2013; Agrawal et al., 2015).   
1.2.1 
Nonclinical Evaluations 
Nonclinical studies with Lymphoseek or tilmanocept demonstrated that the drug selectively 
binds to its intended receptor (the CD206 mannose binding receptor), is appropriately 


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distributed for radiodetection of lymphatic tissue, and is well tolerated by rats, rabbits, guinea 
pigs, and dogs. 
Pharmacokinetics data obtained from nonclinical studies demonstrated rapid absorption into 
the plasma. Urinary excretion was a major pathway of elimination. Lymphoseek exhibited 
rapid clearance from the injection site, rapid uptake by the local lymph node, and low uptake 
by the remaining lymph nodes. Tilmanocept was well tolerated at all doses tested in 
nonclinical safety pharmacology studies and in single and repeated dose toxicology studies in 
rats, rabbits, and dogs. In some studies in rabbits and dogs, tilmanocept acted as a local 
irritant of the subcutis or skeletal muscle, and induced mild inflammation and tissue 
degeneration. The no-observed adverse-effect level (NOAEL) was 42 μg/kg/day. 
Tilmanocept was not mutagenic or genotoxic in vitro or in vivo. No signs or symptoms of 
hypersensitivity were observed in a study in guinea pigs.  
1.2.2 
Clinical Pharmacokinetics and Pharmacodynamics 
In Phase 1 clinical trials, Lymphoseek showed rapid injection site clearance (approximately 
2 to 3 hours). Absolute uptake in the primary sentinel lymph node was dose-related for 
Lymphoseek, although relative nodal uptake (%IDSN) overall was independent of dose and 
ranged from 0.05%IDSN to 1.81%IDSN. 
In a Phase 2 trial, Lymphoseek was highly effective in identifying tumor-draining lymph 
nodes (i.e., overall, a “hot spot” from Lymphoseek was identified in 93.0% of patients for 
whom preoperative lymphoscintigraphy was performed, and the per patient intraoperative 
localization rate was 96.2%). Diagnostic performance of in vivo Lymphoseek findings 
relative to pathology assessment of tumor tissue indicated a high per tissue sensitivity 
estimate (overall, 92.0%). The overall false negative rate (FNR) for pathology was 8.0%, 
supporting the accuracy of Lymphoseek in identifying lymph nodes with a high potential for 
containing tumor metastases in the lymphatics draining the tumor bed. 
1.2.3 
Clinical Efficacy 
Clinical efficacy was evaluated in two pivotal Phase 3 clinical trials in adult subjects with 
breast cancer and melanoma, comparing lymph node detection of Lymphoseek and VBD. 
Lymphoseek demonstrated a statistically significant concordance rate with VBD (meta-
analysis concordance rate = 99.99%). 
The detection concordance between Lymphoseek and VBD was similar among subjects with 
melanoma and subjects with breast cancer (meta-analysis concordance rate = 99.99% for 
both populations). Lymphoseek also demonstrated a higher sensitivity for detecting tumor-
positive (as confirmed by pathology) lymph nodes, corresponding to a decreased FNR when 
compared with VBD on a per node basis. The corresponding sensitivity rate in detection of 
lymph nodes most likely to be positive for tumor cells for Lymphoseek was 99.99%, 
compared with 78.02% for VBD. The FNR for VBD (21.98%) was higher than the FNR for 
Lymphoseek (0.01%). These findings suggest that, when VBD is used as the imaging agent, 
there is an increased risk of missing the detection of tumor-involved lymph nodes and 
incorrectly staging cancer patients. The Lymphoseek-only findings (pathology-positive nodes 


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that were hot/not blue) suggest that Lymphoseek was markedly more effective in identifying 
lymph nodes that harbored disease than was VBD.  
A third pivotal Phase 3 clinical trial was conducted in adult subjects with oral cavity or 
cutaneous SCC.  Subjects received an injection of Lymphoseek prior to surgery for excision 
of the primary tumor and Lymphoseek-guided SLN dissection followed by planned elective 
neck dissection. All excised lymph nodes (Lymphoseek-identified SLNs as well as non-
SLNs) underwent histopathologic evaluation for presence of metastatic disease. The primary 
endpoint in this trial was the Lymphoseek FNR (subjects with pathology-positive lymph 
node(s) not identified by Lymphoseek). Thirty-nine subjects had at least one 
pathology-positive lymph node, and Lymphoseek detected nodes with positive pathology in 
all but one patient. The FNR in this trial was 2.56%.  
1.2.4 
Clinical Safety 
More than 134,000 patients in clinical trials and US commercial use for ILM with SLNB 
have been exposed to Lymphoseek, and there have been no safety signals, no deaths due to 
drug, and no SAEs (serious adverse events) due to Lymphoseek.  There are no known drug 
interactions leading to contraindications with the use of Lymphoseek. 
1.2.5 
Radiation Exposure (Subjects) 
Subjects’ exposure to Lymphoseek delivered as indicated in this protocol will be similar to 
that already established for adult breast cancer, melanoma and head/neck squamous cell 
carcinoma patients.  The radiation absorbed dose for adults is included in the FDA-reviewed 
package insert for the approved product. The OLINDA (for Organ Level INternal Dose 
Assessment) software (Stabin et al., 2005) was used to calculate radiation exposure.  For 
pediatric subjects, the effective dose equivalents range from 355 µSv (15-year-old male) to 
1232 µSv (1-year-old female). Effective dose equivalents for pediatric subjects of various 
ages as well as effective dose by organ is shown in Table 1; values for adults subjects are 
also provided for reference.  
The effective dose equivalents for other technetium 99mTc-based evaluations in children are: 
1) bone scan = 1,800 to 3,000 µSv; and 2) thyroid scan ≈ 3,000 µSv. 
1.2.6 
Radiation Exposure (Health Care Workers and Care Givers) 
Healthcare worker exposure to Lymphoseek delivered as indicated in this protocol will be 
similar to that already established for adult breast cancer, melanoma and head/neck 
squamous cell carcinoma patients. Highest whole body doses (µSv) received by healthcare 
works can be estimated for nuclear medicine staff as < 0.2, surgeons as 1.9, nurses as 0.2 and 
pathology staff as 2.5 such that greater than 400 procedures with Lymphoseek would have to 
be performed prior to reaching an annual exposure of 1000 µSv for non-radiation workers or 
greater then 20,000 procedures prior to reaching an annual exposure of 50,000 µSv for 
radiation workers. 


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Primary caregiver exposure has not been quantified but is assumed to be less than the 
exposure of providing nursing care. Excreta from patients contains very low level radiation 
and will effectively decay to nil in 72 hours. Patients discharged for home pose essentially no 
risk to their co-habitants through regulator social contact. 
Table 1.  
Estimated Radiation Absorbed Dose for a 0.5 mCi, 50 µg Dose of 
Lymphoseek in Intradermal Injection of Cancer Patients  
(Reference Patient is Intradermal Injection of Lymphoseek; Units in mGy) 
 
Target Organ 
Adult 
70 kg 
15 Year Old 
Phantom 
55 kg 
10 Year Old 
Phantom 
33.5 kg 
5 Year Old 
Phantom 
20.3 kg 
1 Year Old 
Phantom 
12.1 kg 
brain 
0.003  
0.0036 
0.00519 
0.00759 
0.01119 
gallbladder wall 
0.0349  
0.04188 
0.060377 
0.088297 
0.130177 
lower large intestinewall 
0.0123  
0.01476 
0.021279 
0.031119 
0.045879 
small intestine 
0.0101  
0.01212 
0.017473 
0.025553 
0.037673 
stomach 
0.0184  
0.02208 
0.031832 
0.046552 
0.068632 
upper large intestine wall 
0.0125  
0.015 
0.021625 
0.031625 
0.046625 
kidney 
0.1863  
0.22356 
0.322299 
0.471339 
0.694899 
liver 
0.0324  
0.03888 
0.056052 
0.081972 
0.120852 
lungs 
0.0374  
0.04488 
0.064702 
0.094622 
0.139502 
muscle 
0.0092  
0.01104 
0.015916 
0.023276 
0.034316 
ovaries 
0.187  
0.2244 
0.32351 
0.47311 
0.69751 
red marrow 
0.0127  
0.01524 
0.021971 
0.032131 
0.047371 
bone 
0.0177  
0.02124 
0.030621 
0.044781 
0.066021 
spleen 
0.0285  
0.0342 
0.049305 
0.072105 
0.106305 
thymus 
0.1168  
0.14016 
0.202064 
0.295504 
0.435664 
thyroid 
0.088  
0.1056 
0.15224 
0.22264 
0.32824 
urinary bladder 
0.0586  
0.07032 
0.101378 
0.148258 
0.218578 
total body 
0.0195  
0.0234 
0.033735 
0.049335 
0.072735 
 
 
EDE (males, mGy) 
0.2960 
0.3552 
0.5121 
0.7488 
1.1040 
EDE (females, mGy) 
0.3302 
0.3962 
0.5712 
0.8354 
1.2316 
 


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2 
STUDY OBJECTIVES 
2.1 
Primary Objective 
To evaluate safety and tolerability of Lymphoseek in pediatric subjects with melanoma, 
rhabdomyosarcoma, or other solid tumors who are undergoing lymph node mapping. 
2.2 
Secondary Objectives 
• To assess the excised lymph node(s) to confirm: the presence/absence of tumor 
metastases; agent localization per tumor type; degree of localization (nodes per subject 
both intraoperatively and with preoperative SPECT. 
• To determine the concordance of in vivo localization rates of Lymphoseek and 
Lymphazurin, a vital blue dye (VBD), in tissue excised and histologically confirmed as 
lymph nodes from those subjects receiving two mapping agents. 
• To record the change of subject stage based on histopathology and make a descriptive 
assessment on change in treatment plan.  
 
 
 


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3 
OVERVIEW OF METHODOLOGY AND DESIGN 
3.1 
Overall Study Design 
This is a prospective, open label, non-randomized, multicenter, blinded pathology assessment 
study to evaluate the tolerability and the diagnostic utility of Lymphoseek in pediatric 
subjects from neonatal to less than 18 years of age with melanoma, rhabdomyosarcoma, or 
other solid tumors where ILM and SLNB is appropriate and tumor resection or biopsy is 
planned. In accordance with local site practice, subjects may also receive Lymphazurin for a 
within-subject comparison of lymph node mapping. 
The proposed study includes 3 visits: A screening visit for initial determination of eligibility 
and evaluation of clinical status, a baseline visit on the day of surgery, and a 4-to 14-day 
safety (in person) follow-up to assess subject disease management.  
The Schedule of Study Events (see Appendix 1) contains a list of all study procedures and 
time points. Study activities are described in detail in Section 7. 
3.2 
Justification for Study Design and Population 
This study is designed to evaluate the use of Lymphoseek as an ILM and SLNB agent in 
pediatric subjects with melanoma, rhabdomyosarcoma, or other solid tumors for which ILM 
and SLNB is useful, and by determining the concordance of detection rates of Lymphoseek 
and of Lymphazurin in the subjects who have utilized both agents. In addition, for each agent 
used, the presence or absence of tumor in the nodes, the number of nodes detected per tumor 
type, and the change in patient staging will be determined. 
As the primary objective of this study is the safety of Lymphoseek in this population, 
Lymphazurin is being used to the extent possible as an optional control in this study for ILM 
endpoints because it would not be feasible to evaluate Lymphoseek’s performance relative to 
another gamma-emitting radiopharmaceutical (i.e., technetium sulfur colloid) in a within-
subject study design. A meaningful comparison of radiopharmaceuticals in a between-subject 
design would necessitate the enrollment of large numbers of subjects, which again would not 
be feasible, given the relatively small incidence of pediatric solid tumors for which ILM and 
SLNB is indicated. Additionally, the use of Lymphazurin is a concomitant procedure that 
provides real-time intraoperative assessment between Lymphoseek and Lymphazurin. Lastly, 
Lymphazurin is an appropriate comparator because lymphatic mapping with a VBD is 
recognized and authorized in the US and multiple EU countries as an experiential clinical 
practice agent, it has been a forming agent in the development of the theory/practice of 
SLNB, and, importantly, its use is supported by ASCO-SSO (Wong et al, 2012) and EANM-
EORTC sentinel node guidelines in melanoma (Chakera et al, 2009). However, due to the 
potential for allergic reactions within this vulnerable population, the use of Lymphazurin is 
optional and should be used consistent with instutitional practice. 


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3.2.1 
Parent/Guardian 
The subject’s parent(s) or guardian(s) will assist in responding to questions and answer 
questions during phone calls, etc., for the duration of the study.  The parent(s) or guardian(s) 
will accompany the study subject to the clinical appointments throughout the study and 
supply information as needed.   
3.2.2 
Rationale for Subject Selection 
No clinical trials have been conducted to evaluate Lymphoseek performance in pediatric 
cancer patients. This study will gather feasibility and safety data in pediatric subjects 
diagnosed with rhabdomyosarcoma, melanoma, or other solid tumors for whom tumor 
resection or biopsy is planned and lymph node mapping is indicated. Melanoma and 
rhabdomyosarcoma represent the most frequently occurring pediatric solid tumor types for 
which ILM is an appropriate procedure.   
3.2.3 
Justification for Radiation Exposure With Proposed Lymphoseek 
Radioactive Dose 
In nuclear medicine imaging, the diagnostic quality of an image is dependent upon the 
number of radioactive events (or counts) detected by the camera in the regions of interest. 
The number of recorded events (counts) increases with the duration of the acquisition period 
and, for a given acquisition period, with the radioactivity administered. Although the injected 
radioactivity should then be high, the higher the applied radioactivity dose, the higher the 
radiation exposure to the subject.  Thus, in nuclear medicine, the optimal radioactive dose for 
a given radiopharmaceutical is usually defined as the lowest radioactive dose that renders an 
image of sufficient quality to provide high diagnostic confidence, commonly referred to as 
ALARA (as low as reasonably achievable) practices for radiation exposure. 
Calculated pediatric effective dose equivalents range from 0.355 mGy (15 year old male) to 
1.232 mGy (1 year old female) as as shown in Table 1 for pediatric subjects of various age. 
3.3 
Protocol Adherence 
Strict adherence to all specifications laid down in this protocol is required for all aspects of 
the study conduct; the investigator may not modify or alter the procedures described in this 
protocol. If protocol modifications are necessary, all alterations that are not solely of an 
administrative nature require a formal protocol amendment (see Section 11.1 for the 
involvement of Institutional Review Board(s) (IRB). 
If an investigator has deviated from the protocol in order to eliminate an immediate hazard to 
subjects or for other inevitable medical reasons, the investigator shall document all such 
deviations, including the reasons thereof, and submit the document to the sponsor and the 
head of the medical institution as applicable. 


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3.4 
Study Duration 
Subjects will be enrolled for approximately 1.5 months depending on the duration of the 
screening window (up to 30 days). 
 


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4 
STUDY POPULATION 
4.1 
Eligibility 
Subjects who fulfill all respective inclusion and none of the exclusion criteria will be eligible 
for enrollment into the study. All inclusion/exclusion criteria must be verified before a 
subject may be considered eligible for enrollment into the study. A subject will be considered 
enrolled in the study on the morning of study Day 1 when they arrive at the study site. 
Written, dated (with time noted) informed consent will be obtained from all subjects. A 
subject who withdraws consent prior to arrival at the study site on Day 1 will be considered a 
screen failure.   
4.1.1 
Inclusion Criteria 
1. The subject's parent(s)/legal guardian(s) understand(s) and voluntarily signed an 
informed consent document prior to any study-related assessments/procedures being 
conducted. Where locally applicable, the subject also understands and voluntarily 
provides his/her assent prior to any study-related assessments/procedures being 
conducted. 
2. Subject has been diagnosed with melanoma, rhabdomyosarcoma, or other tumor where 
tumor resection or biopsy is planned and lymph node mapping is appropriate. 
3. The subject is clinically node negative (cN0) at the time of screening. 
4. Age < 18 years  
5. Male subjects of childbearing potential must be willing to use a condom during sexual 
intercourse and shall not father a child during the course of the study or will practice 
complete abstinence while on study.  
6. Female subjects of childbearing potential must agree to the use of two physician-
approved contraceptive methods simultaneously or practice complete abstinence while on 
study. 
 
4.1.2 
Exclusion Criteria 
1. The subject has had preoperative radiation therapy.  
2. Has had previous surgery or radiation to node basins that would be involved in the ILM 
procedure. 
3. Has a known allergy to dextran or VBD (if intended to be used). 
4. Has a history of alcohol abuse or alcohol dependency in the 3 years before study entry, or 
is an alcoholic or drug addict, as determined by the investigator. 
5. Before the administration of Lymphoseek has received any radiopharmaceutical within 
7 radioactive half-lives of that radiopharmaceutical. 
 
4.1.3 
Justification of Selection Criteria 
Rhabdomyosarcoma and melanoma represent the most frequently occurring pediatric solid 
tumor types for which ILM is an appropriate procedure. While most cases are expected to 
occur in children greater than 2 years of age, younger children who present with these tumor 
types and meet the other eligibility criteria will not be excluded. 


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4.2 
Recruitment 
Subjects will be recruited in accordance with the inclusion and exclusion criteria listed above 
from oncology or pediatric practices. Potentially suitable subjects will be asked by their 
treating specialist about their willingness to participate in this study. At least 20 of the 
recruited subjects will be ≤16 years of age. 
The minimum number of subjects who will be recuited for each age range are indicated in 
Table 2. 
Table 2.   
Minimum enrollment per age group 
Age Range 
Minimum number of enrolled 
and injected subjects 
1 month to < 2 years 
1 
2 to <6 years 
3 
6 to <12 years 
3 
12 to <18 years 
3 
 
The first three subjects between the ages of 2 to 17 will be recruited and injected. Once these 
three subjects have completed the Day-8 safety evaluation, enrollment will be put on hold 
until the Data Safety Monitoring Committee (DSMC) reviews all available safety 
information and agrees to proceed with additional enrollment. If the DSMC concurs, study 
enrollment will then be open to all age cohorts (1 month to <18 years). The DSMC will then 
determine the frequency to meet based on review of the available trial information. 
4.3 
Withdrawal 
In accordance with the Declaration of Helsinki, each subject is free to withdraw from the 
study at any time and without providing a reason. 
A subject who withdraws consent prior to arrival at the study site on Day 1 will be 
considered a screen failure. 
Should a subject withdraw after administration of the investigational product all efforts will 
be made to complete and report the observations up to the time of withdrawal as thoroughly 
as possible. An explanation should be given of why the subject is withdrawing or being 
withdrawn from the study. 
The investigator may withdraw a subject from the study at any time at the discretion of the 
investigator for any of the following reasons:  
• A protocol violation occurs.  


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• A serious or intolerable adverse event (AE) occurs.  
• A clinically significant change in a laboratory parameter occurs.  
• At the investigator’s/sponsor’s discretion as long as it is in the best interest of the subject.  
• The sponsor or investigator terminates the study.  
• The subject or parent/guardian requests to be discontinued from the study. 
4.4 
Replacement 
Subjects will be replaced under the following conditions: 
• Subjects who did not receive study medication or did not proceed to surgery or did not 
undergo lymphatic mapping with lymph node biopsy. 
 
4.5 
Subject Identification 
After the subject and/or parent or guardian provides written informed consent/assent, the site 
will assign the subject a 7-digit subject number. Subject numbers are to be assigned in a 
sequential manner using the following format:  
Digits 1 to 2: Trial number “18”  
Digits 3 to 4: Site number (e.g., “03”)  
Digits 5 to 7: Sequential subject number (e.g., “001”, “002”, “003”, etc.)  
For example, the first subject consented at Site 03 is subject number “18-03-001”.  
Subjects will maintain the same number given at screening for the entire study. If a subject is 
a screen failure, the number will not be used for any other subject. 


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5 
INVESTIGATIONAL PRODUCT 
5.1 
Identification of Investigational Product 
Lymphoseek® (also known as technetium Tc 99m tilmanocept) is a radiopharmaceutical that 
accumulates in lymphatic tissue by binding to mannose binding receptors (CD206) that 
reside on the surfaces of dendritic cells and macrophages. 
5.2 
Investigational Product Dosage and Administration 
Subjects will receive an injection of 50 µg tilmanocept radiolabeled with 0.5 mCi 99mTc. 
Lymphoseek may be administered to a subject as a single injection or as multiple injections. 
The recommended total injection volume for each subject is 0.1 or 0.5 mL administered in a 
single syringe; 0.5 or 1.0 mL in two syringes (0.25 mL or 0.5 mL each); or 0.4 or 1.0 mL 
administered in four syringes (0.1 mL or 0.25 mL each). For subjects with melanoma, 
Lymphoseek will be administered as 1, 2 or 4 intradermal, peritumoral injections or around 
the excision 
biopsy 
site. 
For 
subjects with 
rhabdomyosarcoma or 
other 
solid 
tumors, Lymphoseek will be administered as intradermal peritumoral injection(s) if 
anatomically appropriate or, if not possible, injection should be performed as 
determined clinically appropriate by the surgeon. 
All doses will be provided in 1 mL BD Luer-LokTM syringes. Each syringe will be delivered 
with a ½ inch 25-30 gauge needle that can remain or can be replaced with an alternate needle 
as selected by the surgeon or nuclear medician physician as most appropriate for the 
individual subject’s tumor type. The final administered dose will be ± 20 % of the intended 
dose (0.4 to 0.6 mCi). 
5.3 
Vital Blue Dye 
Any investigational site with current experience and standard practice with VBD will use 
Lymphazurin (1% isosulfan blue injection). Other dyes should not be used. Lymphazurin is 
commercially available and will be ordered and administered to subjects at the start of or 
during the surgical procedure as part of their standard of care, per institutional practice. The 
injection will be performed as deemed appropriate by the surgeon and in accordance with the 
standard of care at the clinical site. 
5.4 
Treatment Assignment 
In this open-label, non-randomized study, all subjects will receive the same Lymphoseek 
treatment. The use of Lymphazurin is optional, consistent with institutional practice. 
5.5 
Packaging and Labeling 
Tilmanocept Powder kits ready for radiolabeling will be shipped and stored at the region-
specific Cardinal Health radiopharmacy or clinical site radiopharmacy performing the 
radiolabeling. Tilmanocept Powder is provided in a 250-microgram vial.  A carton contains 
five vials of tilmanocept. One kit, which is one tilmanocept vial, should be used for each 


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subject. The carton also contains five shield labels and 25 syringe labels. This package has 
been designed specifically for tilmanocept and protects the vials during shipment, handling, 
and storage. Cardinal will provide a radiolabeling protocol and Quality Control worksheets. 
If the clinical site uses a Cardinal Health radiopharmacy, the Cardinal Health radiopharmacy 
will radiolabel tilmanocept with 0.5 mCi of 99mTc and deliver single or multiple syringes that 
are ready for injection to the clinical site radiopharmacy. 
5.6 
Drug Logistics and Accountability 
The investigator (or designated personnel) will confirm receipt of the investigational product 
in writing and will use the investigational product only within the framework of this clinical 
study and in accordance with this study protocol. For each subject he/she will keep a record 
of the investigational product dispensed and store all other forms that accompanied the 
delivery of the radiolabeled investigational product to the clinical site. These documents are 
to be filed in the Investigator Site File. Overall drug accountability and reconciliation will be 
completed by the sponsor or its representative. A list of investigational product vials or 
syringes and other materials that were returned, or destroyed, must be prepared and signed by 
the principal investigator or an appropriately qualified designee as documented in the study 
site responsibility sheet. An overall accountability and reconciliation form of the 
investigational product will also be prepared and completed. If there are any discrepancies, 
an explanation for these must be provided. 
 


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6 
THERAPIES OTHER THAN INVESTIGATIONAL PRODUCT 
6.1 
Prior and Concomitant Therapy 
All medications taken 30 days prior to Lymphoseek injection through the Day 4 to 14 follow-
up will be documented. 
6.2 
Post-Study Therapy  
Not applicable. 


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7 
SCHEDULE OF EVALUATIONS AND VISIT DESCRIPTION 
7.1 
Schedule of Evaluations 
Evaluations will be performed during a period of up to 14 days post Lymphoseek 
administration, following a screening period of maximum 30 days. A schedule of evaluations 
is provided in the Schedule of Events (see Appendix 1). 
7.2 
Visit Description 
7.2.1 
Screening Visit (Day -29 to Day 0) 
• Preliminary review of inclusion and exclusion criteria 
• Obtain signed informed consent for study participation 
• Allocation of unique subject number; this number will be used to document the 
subject data in the eCRF (case report form) and enrollment log 
• Demography – Date of birth, gender, and race 
• Medical history – Medical history will be obtained on all study subjects.  All relevant 
prior medical conditions will be recorded in the eCRFs.  Documented medical 
conditions will also note the month/year of onset and if the condition is active.  
• Cancer staging – tumor, lymph node, metastasis staging (TNM) (Edge, 2010) 
information will be collected.  
• Performance status will be collected using the Lansky (Lansky et al, 1987) or 
Karnofsky (Karnofsky et al, 1948) scale as determined by age. 
• Vital signs – Vital signs will include body temperature (°F or °C), respiratory rate, 
pulse rate, and systolic and diastolic blood pressures. Prior to obtaining blood 
pressures and pulse, the subject should be in a resting position for at least 1 minute.  
Body weight (in pounds) and height (in inches) without shoes will be recorded only at 
the screening evaluation. 
• ECG – The ECG (electrocardiogram) reading will be assessed for clinical 
significance by the investigator, and any clinically significant abnormal findings will 
be noted on the subject’s medical history and should be transmitted to the Central 
ECG Reader within 1 business day. 
• Physical exam – Physical examinations will include examination of general 
appearance, skin, eyes, ears, nose, throat, head and neck (including thyroid), lungs, 
heart, abdomen, lymph nodes, musculoskeletal, and nervous system. Physical exams 
that are conducted as standard of care prior to signing informed consent may be used 
if they are performed within 30 days of injection. 
• Clinical laboratory tests – Study subjects will have blood and urine samples obtained 
for hematology, chemistry, and urinalysis (See Section 8.8.2). [Alternatively, blood 
and urine may be collected on Day 1 if performed before Lymphoseek injection.] 
• Concomitant medications (within 30 days before surgery). 
• Final check of inclusion/exclusion criteria 


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7.2.2 
Before Enrollment 
Within 48 hours prior to receiving the Lymphoseek injection, a urine or serum pregnancy test 
will be conducted for female subjects of childbearing potential as defined as having reached 
menarche.   
Subject care provider/guardian will be questioned to determine if a change in medical history 
or concomitant medications has occurred since the last visit. 
7.2.3 
Preparation of Lymphoseek 
The indicated dose of Lymphoseek should be ordered from the Cardinal Health 
radiopharmacy or clinical site radiopharmacy by the Nuclear Medicine Department once the 
subject has been scheduled for surgery.  
The following medications are not permitted as co-injected drugs: local anesthetics, e.g., 
procaine, xylocaine, lidocaine, or carbocaine. 
7.2.4 
Day 1: Before Injection 
Before receiving the Lymphoseek injection, vital signs will be collected.  Vital signs will 
include body temperature (°F or °C), respiratory rate, radial pulse rate, and systolic and 
diastolic blood pressures. Prior to obtaining blood pressures and pulse, the subject should be 
resting quietly for 1 minute. Body weight and height measurements are not required. 
Each syringe will be assayed individually and recorded in the source documentation prior to 
injection. 
7.2.5 
Day 1: Injection of Lymphoseek 
Injection of Lymphoseek will be at study time 0:00. Subjects will receive 50 µg tilmanocept 
radiolabeled with 0.5 mCi 99mTc by injection as described in Section 5.2. 
7.2.6 
Day 1: Post Injection 
Vital signs will be collected at 10 minutes, 30 minutes, and 1 hour post-injection and after 
surgery. Vital signs will include body temperature (°F or °C), respiratory rate, pulse rate, and 
systolic and diastolic blood pressures. Before blood pressures and pulse are obtained, the 
subject should be resting quietly for 1 minute. Body weight and height measurements are not 
required. Allowable windows for vital sign collection are as follows: 
0:10, 0:30 = ± 3 minutes  
 
1:00 hour = ± 5 minutes 


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An ECG will be recorded on Day 1 at least 10 minutes after Lymphoseek injection. The ECG 
reading will be reviewed by the investigator, and any clinically significant abnormal findings 
will be noted as an AE. 
Each syringe will be assayed individually and recorded in the source documentation after 
injection. 
7.2.7 
Day 1: Imaging and Surgery 
Dynamic and/or planar SPECT or SPECT/CT imaging may be performed prior to surgery as 
described in Section 8.3, and any finding will be documented and recorded on the appropriate 
CRF. 
Vital signs and ECGs will be recorded as described in Section 7.2.6. 
If Lymphazurin is to be used, it should be administered in the operating room at the start of 
or during surgery prior to transcutaneous surveying. The injection will be performed as 
deemed appropriate by the surgeon and in accordance with the standard of care at the clinical 
site. Fifteen minutes to 8 hours after Lymphoseek injection, subjects will undergo surgery to 
remove the primary tumor, ILM will be performed, and SLN(s) will be harvested. Locations 
of both hot and blue (when applicable) nodes will be recorded. 
7.2.8 
Day 1: After Surgery 
Clinical laboratory evaluations (chemistry, hematology and urinalysis), review of 
medications, and AE monitoring will be performed. Medications administered for anesthesia 
related to surgery do not need to be captured in the eCRFs. 
7.2.9 
Day 4 to 14: Postsurgical Safety Follow-up  
Vital sign assessment, physical examination, review of medications, and AE monitoring will 
be performed. The post surgical treatment plan and TNM staging will be collected for all 
subjects. Clinical group will be collected for subjects with rhabdomyosarcoma.  
7.2.10 
End of Study  
The Day 4 to 14 Follow-up visit will serve as the end of study visit. 


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8 
PROCEDURES AND VARIABLES 
8.1 
Population Characteristics 
8.1.1 
Demographic and Other Baseline Characteristics 
Male or female pediatric subjects aged <18 years (at least 20 of the subjects will be ≤16 years 
of age) will be enrolled. For the primary analysis, at least 27 subjects will be injected with 
Lymphoseek. This population of subjects will include at least 6 subjects with melanoma, at 
least 6 subjects with rhabdomyosarcoma, with enrollment open to up to an additional 15 
subjects with other solid tumors for which ILM and SLNB are appropriate. At least 25 
subjects will complete the 4-to 14-day follow up. 
8.1.2 
Medical and Surgical History 
Medical and surgical history will be obtained on all trial subjects. All relevant medical 
conditions (current and prior), month/year of onset, and if the condition is currently active 
will be recorded in the eCRFs. Common accepted medical terminology should be used. 
8.1.3 
Staging  
All subjects will be assigned TNM classification and clinical stage prior to the primary 
surgical intervention. After the primary surgical intervention, TNM classification will be 
updated along with the pathological stage. The TNM Staging System is based on the extent 
of the tumor (T), the extent of spread to the lymph nodes (N), and the presence of metastasis 
(M). Table 3, Table 4, Table 6, and Table 7 include applicable definitions for 
rhabdomyosarcoma (National Cancer Institute, 2015, http://www.cancer.gov) and melanoma 
(American Joint Cancer Staging Manual, 7th edition). For staging of other tumor types, the 
TNM staging will be applied as made available by the AJCC. Subjects with 
rhabdomyosarcoma will be additionally classified by clinical group (National Cancer 
Institute, 2015) which is based on the extent of the disease and how completely it is removed 
during the primary surgical intervention at the end of their trial participation as indicated in 
Table 5. 
 
 


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Table 3. 
Rhabdomyosarcoma TNM Classification 
Term 
Definition 
Favorable 
Orbit; nonparameningeal head and neck; genitourinary tract other than 
kidney, bladder, and prostate; biliary tract. 
Unfavorable 
Any site other than favorable. 
T1 
Tumor confined to anatomic site of origin (noninvasive). 
T2 
Tumor extension and/or fixation to surrounding tissue (invasive). 
   A 
Tumor ≤5 cm in maximum diameter. 
   B 
Tumor >5 cm in maximum diameter. 
N0 
No clinical regional lymph node involvement. 
N1 
Clinical regional lymph node involvement. 
NX 
Regional lymph nodes not examined; no information. 
M0 
No metastatic disease. 
M1 
Metastatic disease. 
 
 


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Table 4. 
Rhabdomyosarcoma Staging 
Stage 
Definition 
1 
Favorable sites. 
T1 or T2 any size. 
N0 or N1 or NX. 
M0. 
2 
Unfavorable sites. 
T1 or T2, less than or equal to 5 cm. 
N0 or NX. 
M0. 
3 
a: Unfavorable sites. 
T1 or T2, less than or equal to 5 cm. 
N1  
M0. 
b: Unfavorable sites. 
T1 or T2, greater than 5 cm. 
N0 or N1 or NX.  
M0. 
4 
Any site. 
T1 or T2, any size. 
N0 or N1 or NX.  
M1. 
 
 


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Table 5. 
Clinical Group Rhabdomyosarcoma 
Group 
Definition 
I 
Localized tumor, completely removed with microscopically clear margins and 
no regional lymph node involvement.  
II 
Localized tumor, completely removed with: (a) microscopic disease at the 
margin; (b) regional disease with involved, grossly removed regional lymph 
nodes without microresidual disease; or (c) regional disease with involved 
nodes, grossly removed but with microscopic residual and/or histologic 
involvement of the most distal node from the primary tumor. 
III 
Localized tumor, incompletely removed with gross, residual disease after: (a) 
biopsy only or (b) gross major resection of the primary tumor (>50%). 
IV 
Distant metastases are present at diagnosis. This category includes: (a) 
radiographically identified evidence of tumor spread and (b) positive tumor 
cells in cerebral spinal fluid, pleural, or peritoneal fluids, or implants in these 
regions. 
 
 
 


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Table 6. 
Melanoma TNM Classification 
Term 
Definition 
Tis 
Melanoma in situ 
T1a 
≤1.0 mm in thickness without ulceration; mitosis <1/mm2 
T1b 
≤1.0 mm in thickness with ulceration or mitoses ≥1/mm2 
T2a 
1.01–2.0 mm in thickness without ulceration 
T2b 
1.01–2.0 mm in thickness with ulceration 
T3a 
2.01–4.0 mm in thickness without ulceration 
T3b 
2.01–4.0 mm in thickness with ulceration 
T4a 
>4.0 mm in thickness without ulceration 
T4b 
>4.0 mm in thickness with ulceration 
N0 
No regional metastases 
N1 
1 regional lymph node metastasis 
N1a 
1 regional node metastasis with micrometastasis 
N1b 
1 regional node metastasis with macrometastasis 
N2 
2–3 regional lymph node metastases 
N2a 
2–3 regional lymph node metastases with micrometastasis 
N2b 
2–3 regional lymph node metastases macrometastasis 
N2c 
In transit met(s)/satellite(s) without metastatic lymph nodes 
N3 
≥4 regional lymph node metastases; or matted nodes; or in transit 
met(s)/satellite(s) with metastatic lymph node(s) 
NX 
Regional lymph nodes not examined; no information. 
M0 
No detectable evidence of distant metastases 
M1a 
Metastases to skin, subcutaneous, or distant lymph nodes and normal serum 
LDH 
M1b 
Metastases to lung and normal serum LDH 
M1c 
Metastases to all other visceral sites and normal serum LDH; or distant 
metastases to any site and elevated serum LDH 
 
 
 


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Table 7. 
Melanoma Staging 
Term 
Definition 
Stage 0 
Tis, N0, M0  
Stage IA 
T1a, N0, M0 
Stage IB 
T2a, N0, M0 or 
T1b, N0, M0 
Stage IIA 
T2b, N0, M0 or 
T3a, N0, M0 
Stage IIB 
T3b, N0, M0 or 
T4a, N0, M0 
Stage IIC 
T4b, N0, M0 
Stage III 
Any T, N1-N3, M0 
Stage IIIA 
T1a, N1a, M0 or 
T2a, N1a, M0 or 
T3a, N1a, M0 or 
T4a, N1a, M0 or 
 
T1a, N2a, M0 or 
T2a, N2a, M0 or 
T3a, N2a, M0 or 
T4a, N2a, M0 
Stage IIIB 
T1b, N1a, M0 or 
T2b, N1a, M0 or 
T3b, N1a, M0 or 
T4b, N1a, M0 or 
 
T1b, N2a, M0 or 
T2b, N2a, M0 or 
T3b, N2a, M0 or 
T4b, N2a, M0 or 
 
T1a, N1b, M0 or 
T2a, N1b, M0 or 
T3a, N1b, M0 or 
T4a, N1b, M0 or 
 
T1a, N2b, M0 or 
T2a, N2b, M0 or 
T3a, N2b, M0 or 
T4a, N2b, M0 or 
 
T1a, N2c, M0 or 


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Term 
Definition 
T2a, N2c, M0 or 
T3a, N2c, M0 or 
T4a, N2c, M0 
Stage IIIC 
T1b, N1b, M0 or 
T2b, N1b, M0 or 
T3b, N1b, M0 or 
T4b, N1b, M0 or 
 
T1b, N2b, M0 or 
T2b, N2b, M0 or 
T3b, N2b, M0 or 
T4b, N2b, M0 or 
 
T1b, N2c, M0 or 
T2b, N2c, M0 or 
T3b, N2c, M0 or 
T4b, N2c, M0 or 
 
Any T, N3, M0 
Stage IV 
Any T, any N, M1(a, b, or c) 
 
8.1.4 
Performance Status 
All subjects will be evaluated at screening for performance status (Table 8). Karnofsky Scale 
will be used for children 16 years of age and older. The Lansky scale will be used for 
subjects less than 16 years of age. The table below will be used to assign the performance 
score. 
Table 8.   
Performance Status Scale 
Karnofsky Scale (age >16 years) 
Lansky Scale (age <16 years) 
100 
Normal, no complaints, no 
evidence of  disease 
100 
Fully active 
90 
Able to carry on normal activity 
90 
Minor restriction in physically 
strenuous play 
80 
Normal activity with effort 
80 
Restricted in strenuous play, tires 
more easily, otherwise active 
70 
Cares for self, unable to carry on 
normal activity or to do work 
70 
Both greater restrictions of, and 
less time spent in active play 


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Karnofsky Scale (age >16 years) 
Lansky Scale (age <16 years) 
60 
Requires occasional assistance but 
is able to care for most needs 
60 
Ambulatory up to 50% of time, 
limited active play with 
assistance/supervision 
50 
Requires considerable assistance 
and frequent medical care 
50 
Considerable assistance required 
for any active play, fully able to 
engage in quiet play 
40 
Disabled, requires special care and 
assistance 
40 
Able to initiate quiet activities 
30 
Severely disabled, hospitalization 
indicated, although death not 
imminent 
30 
Needs considerable assistance for 
quiet activity 
20 
Very sick, hospitalization 
necessary 
20 
Limited to very passive activity 
initiated by other (e.g., TV) 
10 
Moribound, fatal process 
progressing rapidly 
10 
Complete disabled, not even 
passive play 
 
8.1.5 
Prior and Concomitant Medication 
All prior medication used within the last 30 days before the first screening examination and 
concomitant medications will be documented. Medications administered for general 
anesthesia related to surgery do not need to be captured in the eCRFs. 
8.2 
Lymphoseek Preparation and Injection 
The 0.5 mCi dose of Lymphoseek should be ordered from the Cardinal Health or clinical site 
radiopharmacy once the subject has been scheduled for surgery.  
Injection of Lymphoseek will be at study time 0:00. Subjects will receive an injection of 
50 µg tilmanocept radiolabeled with 0.5 mCi 99mTc +/- 20% as described in Section 5.2. 
Local anesthetics are not permitted as co-injected drugs: e.g., procaine, xylocaine, lidocaine 
or carbocaine. 
8.3 
SPECT/SPECT-CT or Other Gamma Image Acquisition and Image 
Transfer 
After safety measurements have been completed and before surgery, subjects may undergo 
lymphoscintigraphy according to institutional imaging protocols.The camera used to obtain 
images should be equipped with a low-energy, high-resolution collimator and be peaked at 
140 KeV with a 20% window centered over the peak. The subject should be imaged in the 
same position used for surgery so that there is no shift if the sentinel node is marked on the 
skin whenever possible. Imaging for melanoma and rhabdomyosarcoma/other solid 
tumors subjects may commence at the time of injection (if performing dynamic imaging).  If 


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performed, imaging should not conclude less than15 minutes post injection and should be 
completed no later than 60 minutes after injection. 
It is strongly recommended that each site should perform all imaging acquisitions per their 
camera manufacturer and model parameters and in accordance with their institutional 
practices.  
 
Once a sentinel node is identified, a radioactive marker should be placed over skin while the 
subject is under the camera detector, keeping the SLN in the field of view. The marker 
should be moved until the marker and SLN overlap, this area should be marked with 
waterproof ink.  
All images should be reviewed by a radiologist for quality prior to the subject being sent to 
surgery.  
If collected, a deidentified Digital Imaging and Communications in Medicine (DICOM) copy 
of all images should be transmitted to Cardinal using the provided source worksheet and file 
pathway provided by your Project Manager. 
8.4 
Surgical Procedures, Lymphatic Mapping, and Lymph Node 
Biopsy 
8.4.1 
Lymphoseek-Designated “Hot” Nodes 
Room Background Count 
Using the handheld gamma detection system a room background shall be determined by 
recording three 2-second counts or one 10-second count obtained at least 30 cm away from 
the injected subject and any other radiation source.  
Normal Tissue Background Count 
Using the handheld gamma detection system, identify an anatomical region greater than 
20 cm from the Lymphoseek injection site and not over the abdomen. A set of three 2-second 
counts or one 10-second count on non-lymphoid tissue (background counts) are obtained to 
set the threshold criteria. 
In Vivo 
In vivo Lymphoseek positivity is based on radioactivity counts derived from the application 
of the handheld gamma probe in vivo, where such counts must satisfy the threshold criterion 
of greater than the quantity of 3 times the square root of the mean normal tissue background 
count (i.e., standard deviation) added to the mean normal tissue background count (referred 
to as the “3σ rule”). Any nodal count NOT meeting this threshold criterion will be considered 
a negative finding (not localized). Use the Gamma Detector Counts Calculation Sheet, 
Appendix 2 to assist in determining the 3σ level from the normal tissue background level. 


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Ex Vivo 
Ex vivo Lymphoseek positivity is based on radioactivity counts derived from the application 
of the handheld gamma probe ex vivo (excised from the subject), where such counts must 
satisfy the threshold criterion of greater than the quantity of 3 times the square root of the 
mean normal tissue background count (i.e., standard deviation) added to the mean normal 
tissue background count (referred to as the “3σ rule”). Any nodal count NOT meeting this 
threshold criterion will be considered a negative finding (not localized). Use Appendix 2 to 
assist in determining the 3σ level from the normal room background level. 
8.4.2 
Surgical Lymph Node Identification 
1. If Lymphazurin is used, inject it into the dermis around the primary tumor site (see 
Lymphazurin insert for instructions) in accordance with institutional standards. No 
more than 3 mL will be injected. 
2. Conduct an initial transcutaneous survey to identify the area of increased radioactivity 
that is separate from the injection site. The survey should include the entire lymph 
node (LN) basin(s) at risk. 
3. Once an area of increased radioactivity is identified, an incision should be placed to 
make as direct an approach as possible to the LNs.   
4. On entering the subcutaneous tissue, a blue lymphatic vessel or blue lymph node may 
be seen. If a blue lymphatic vessel is seen, carefully trace it proximally to a blue LN. 
In vivo counts should be recorded and LN removed. 
OR 
If no blue lymphatic vessel or blue lymph node is seen, or if Lymphazurin is not used, 
then using a combination of visualization and the handheld gamma detector, explore 
the lymphatic basin for the LNs. As dissection proceeds towards the LN, repeated use 
of the handheld gamma detector is helpful in maintaining a line of site to the lymph 
node. The count rate will increase as dissection approaches the Lymphoseek-
containing lymph node(s).  
5. Once an LN has been identified, in vivo counts should be taken prior to excision. In 
vivo counts will consist of a set of three 2-second counts or one 10-second count 
(depending on the device) over the lymph node. Determination of a positive finding 
(i.e., localization) is based on the in vivo definition above. Any LN count not meeting 
this threshold criterion will be considered a negative (non-localized) finding.   
6. The method used to identify all LN(s) will be recorded (i.e., blue appearance, positive 
finding, or both) prior to excision. 
7. To confirm the in vivo procedure, a set of three 2-second counts or one 10-second 
count will be recorded for the excised lymph nodes. The mean count of the ex vivo 
LN will be compared to the mean of normal tissue background counts, and the 
threshold criterion used to determine a positive finding for the in vivo LNs will be 
applied to the ex vivo specimens. The appearance and time of excision of the lymph 
node will be documented. Determination of a positive finding (i.e., localization) is 


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based on the ex vivo definition above. Ex vivo counts must be performed on all 
excised lymph nodes. 
Table 9 describes the procedures that should be followed based on the in vivo and ex vivo 
status of the tissue that has been excised. 
 
Table 9.   
Handling of Excised Tissue  
In Vivo Assessment 
Ex Vivo Assessment 
Procedure 
Radioactive Status 
positive (hot) 
positive (hot) 
Send to pathology for further evaluation. 
positive (hot) 
negative (not hot) or no 
counts obtained 
Incorrect node harvested. Send to pathology for 
further evaluation. Return to resection bed. 
negative or no counts (not 
hot) 
positive (hot) 
Comment on why lymph node was removed. Send 
to pathology for further evaluation. 
Vital Blue Dye Status 
Blue node 
N/A 
ANY blue node is sent to pathology for further 
evaluation regardless of radioactive status. 
 
8. A thorough evaluation of the remaining lymphatic basin should be undertaken since 
more than one LN may be found. This evaluation should include a combination of 
palpation, visualization, and gamma detector survey for evidence of blue and/or 
increased gamma detector count rates. 
9. Probing of the area will be complete when all selected node counts are negative by 
use of the threshold criterion. The surgeon will continue with visualization and 
palpation according to local practice to ensure that no grossly positive LNs remain at 
the site of resection.  
If a subject has neither a blue node nor any “hot” nodes, continue with visualization 
and palpation according to your medical expertise.  
All removed LNs must be sent to pathology for further evaluation. The pathological 
evaluation of lymph node(s) will include serial sectioning and staining as described below 
(see also the Pathology Manual for additional details). For the purposes of analysis, a sentinel 
lymph node is defined as either being hot in vivo (lymph nodes with counts above the 3σ rule 
threshold) or blue (when applicable). 
8.5 
Histopathology of Lymph Nodes 
8.5.1 
Local Lymph Node Evaluation 
Final pathology results need to reflect consistent individual numbering and labeling from 
intraoperative worksheets to the final pathology report. All LNs should be fixed in 10% 
neutral phosphate buffered formalin for 6 to 24 hours, processed, and embedded in paraffin. 
All lymph nodes greater than 0.5 cm should be bisected transversely to the long axis or along 
the long axis prior to fixation. The entire lymph node should be submitted for histological 


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evaluation. Local pathology assessment of the lymph nodes should be conducted according 
to the institution’s current practices. 
8.5.2 
Preparation and Shipping of Lymph Node Samples to Central Laboratory 
Paraffin blocks can be submitted directly to the central laboratory for slide and stain 
processing.  Alternatively, sites can send slides.  If slides are to be sent, the local pathology 
laboratory will section the tissue into levels from the superficial surface to produce three 
levels. Each level will be cut such that it is 750 microns (0.75 mm) deeper than the previous 
level. Eight unstained slides will be generated from each level of tissue and should be cut at 
3 to 5 µm thickness and placed on plus glass slides. In the event that the tissue thickness in a 
given block is less than 0.25 inches thick, only two levels will be cut, with 8 slides submitted 
from each level. 
The blocks or unstained slides will be shipped to the central laboratory using kits supplied to 
the trial site along with instructions and prepaid shipping labels. All slides will be maintained 
by the central laboratory until trial completion. Contact information and additional 
preparation and shipping instructions are maintained in the Study Operations Manual and 
Pathology Manual. 
Shipments as well as questions regarding logistics, quality assurance, or documentation can 
be directed to the central pathology laboratory.   
8.5.3 
Central Laboratory Processing of Samples 
The central pathology laboratory will process samples with hematoxylin and eosin (H&E) 
and immunohistochemistry (IHC) stains. Processing will be in accordance with the detailed 
guidelines specified in the Pathology Manual.  
Central pathology laboratory results will be entered into the eCRFs by designated central 
pathology laboratory staff. 
The pathology evaluation of each node shall be reported as follows: 
A - Macrometastases (>2 mm) 
B - Micrometastases (≤2.0 mm and ≥0.2 mm) 
C - Isolated tumor cells or <0.2 mm 
D - No observable tumor presence 
8.6 
Pharmacokinetics 
No pharmacokinetic investigation will be performed in this study. 


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8.7 
Safety 
8.7.1 
Adverse Events 
8.7.1.1 
Definition of Adverse Event 
The definitions below follow International Conference on Harmonization (ICH) – Good 
Clinical Practice (GCP) (see also ICH Guideline for Clinical Safety Data Management: 
Definitions and Standards for Expedited Reporting). 
Adverse Event (AE) 
An AE is defined as any untoward medical occurrence in a subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal (investigational) product, whether or not considered related to the medicinal 
(investigational) product. 
By definition for this study, all untoward medical occurrences beginning on the day of 
injection through the 4- to 14-day follow-up assessment are to be reported as AEs. 
Additionally, untoward medical events occurring prior to the day of injection will only be 
captured as AEs if they are related to a study procedure. SAEs will be reported from the time 
of consent through the end of participation. All adverse events should be followed until 
resolution or stabilization as determined by the investigator. 
8.7.1.2 
Categories for Adverse Event Assessment 
All AEs will be assessed and documented by the investigator according to the categories 
detailed below. 
Seriousness 
For each AE, the seriousness must be determined according to the criteria given in 
Section 8.7.1.5. 
Severity 
The intensity of an AE is classified according to the following categories, taking into account 
the possible range of the intensity of the event: 
• Mild   
The adverse event is transient and easily tolerated by the subject. 
• Moderate  The adverse event causes the subject discomfort and interrupts the subject’s 
usual activities 
• Severe  
The adverse even causes considerable interference with the subject’s usual 
activities and may be incapacitating or life-threatening. 


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Specific drug treatment 
Any specific drug treatment will be documented. 
Causal relationship to investigational product and/or Lymphazurin (VBD) 
The investigator will use the following definitions to assess the relationship of the AE to the 
use of investigational product and/or Lymphazurin:  
Definitely related: 
Event can be fully explained by administration of the 
investigational product and/or Lymphazurin. 
Probably related: 
Event is most likely to be explained by administration of the 
investigational product and/or Lymphazurin rather than the 
subject’s clinical state or other agents/therapies. 
Possibly related: 
Event may be explained by administration of the investigational 
product and/or Lymphazurin or by the subject’s clinical state or 
other agents/therapies. 
Probably not related: 
Event is most likely to be explained by the subject’s clinical state 
or other agents/therapies, rather than the investigational product 
and/or Lymphazurin. 
Definitely not related: 
Event can be fully explained by the subject’s clinical state or other 
agents/therapies. 
For causality assessments, AEs meeting the categories of definitely, probably, or possibly 
related will be considered to be related to investigational product and/or Lymphazurin. 
Causal relationship to study procedure 
The investigator will use the following definitions to assess the relationship of the AE to the 
study procedure:  
Definitely related: 
Event can be fully explained by the study procedure. 
Probably related: 
Event is most likely to be explained by the study rather than the 
subject’s clinical state or other agents/therapies. 
Possibly related: 
Event may be explained by the study procedure or by the subject’s 
clinical state or other agents/therapies. 
Probably not related: 
Event is most likely to be explained by the subject’s clinical state 
or other agents/therapies, rather than the study procedure. 
Definitely not related: 
Event can be fully explained by the subject’s clinical state or other 
agents/therapies. 


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For causality assessments, events meeting the categories of definitely, probably, or possibly 
related will be considered to be related to the study procedure. 
8.7.1.3 
Assessments and Documentation of Adverse Events  
Any AE (observed, volunteered, or elicited) should be recorded in detail in the source 
documentation. 
The following information is required: 
• The date and time of onset of any AE 
• The date and time the AE ends 
• The seriousness of the AE will be assessed by the investigator.  If the investigator deems 
that an AE qualifies as a serious adverse event (SAE), a special form provided by the 
sponsor should be completed and the event must be immediately reported to the sponsor.  
A definition of serious adverse events is provided below.   
• The maximum intensity (mild, moderate, or severe) 
• Whether drug treatment was administered for the event 
• The relationship of the AE to the investigational product and to study conduct (for 
definitions, see above) 
• The outcome of the AE (Resolved, Resolved with sequelae, Ongoing, Unknown, Lost to 
Follow-up, Death) 
AEs will be coded according to an internationally recognized dictionary (Medical Dictionary 
for Regulatory Activities or MedDRA). 
8.7.1.4 
Expected Adverse Events 
Expected Conduct-Related AEs 
AEs are determined by the investigator. If in the investigator’s opinion/experience an event is 
expected and not uncommon for that surgery (i.e., nausea in the recovery room), and it is not 
deemed different in severity from other episodes observed in the same situation, then it is up 
to the investigator’s discretion to determine the event to be adverse. 
An example of an expected conduct-related event: The use of an intravenous blood collection 
and indwelling venous cannula for the purpose of blood sampling and administration of 
investigational product may be accompanied by mild bruising and also, in rare cases, by 
transient inflammation of the vessel wall. After initial irritation, the presence of an 
indwelling cannula is usually painless and hardly noticeable. The same applies to single vein 
punctures for blood sampling. 


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Expected Adverse Drug Reactions 
The definition below follows ICH-GCP (see also ICH Guideline for Clinical Safety Data 
Management:  Definitions and Standards for Expedited Reporting): 
Adverse Drug Reaction (ADR): In the pre-approval clinical experience with a new medicinal 
product or its new usages, particularly as the therapeutic dose(s) may not be established, all 
noxious and unintended responses to a medicinal product related to any dose should be 
considered as ADR. The phrase ‘responses to a medicinal product’ means that a causal 
relationship between a medicinal product and an AE is at least a reasonable possibility 
(definitely, probably, possibly), i.e., the relationship cannot be ruled out. 
Investigational Product-Related Risks 
In all completed clinical trials of Lymphoseek, involving 553 subjects, only 3 events (breast 
pain and injection site pain reported by subjects with breast cancer and injection site irritation 
reported by a subject with head and neck squamous cell cancer) were deemed definitely 
related to the administration of Lymphoseek by the investigator. The most common adverse 
reactions (incidence <1%) are injection site irritation and/or pain. 
Adverse events from the radioactive dose are not expected, since the applied radiation doses 
are far below doses that can cause acute effects in human tissues. 
Precautionary Measures 
Special precautionary measures are not considered to be necessary for this study. In case of 
emergency, standard emergency procedures will be employed. 
Unexpected Adverse Drug Reactions 
An unexpected adverse drug reaction is defined as an adverse reaction that in nature and 
severity is not consistent with the applicable product information (e.g., Investigator’s 
Brochure). 
Any adverse experience that is not listed in the current Investigator’s Brochure or which is, 
with regard to the specificity or severity, not consistent with the risk information shall be 
regarded as unexpected. 
Examples would be (a) acute renal failure listed in the Investigator’s Brochure with a 
subsequent new report of interstitial nephritis and (b) hepatitis with a first report of fulminant 
hepatitis. “Unexpected” as used in this definition refers to an adverse drug experience that 
has not been previously observed and included in the product information, rather than from 
the perspective of such experience not being anticipated from the pharmacological properties 
of the investigational product. 


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8.7.1.5 
Serious Adverse Events  
Definition of Serious Adverse Events 
Definition 
The following SAE definition is based on ICH guidelines and the final rule issued by the 
Food and Drug Administration (FDA) and effective 06 Apr 1998. It is to be applied to AEs 
(defined in Section 8.7.1.1). 
An SAE is classified as any untoward medical occurrence that at any dose: 
• results in death, or 
• is life threatening, or 
• requires inpatient hospitalization or prolongation of existing hospitalization, or 
• results in persistent or significant disability/incapacity, or 
• is a congenital anomaly/birth defect, or 
• is an important medical event (see paragraphs below). 
The term ‘life threatening’ in the definition refers to an event in which the subject was at risk 
of death at the time of the event; it does not refer to an event that hypothetically might have 
caused death if it were more severe. 
Medical and scientific judgment should be exercised in deciding whether it is appropriate to 
report an AE as serious also 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 
definition above. These should also usually be considered serious. Examples of such events 
are intensive treatment in an emergency room or at home for allergic bronchospasm or blood 
dyscrasias or convulsions that do not result in subject hospitalization. 
Hospitalizations or other acute events that fall within the definition of SAE for planned 
elective surgeries,  surgeries anticipated as part of the subject’s primary surgical intervention 
such as reconstruction or plastic surgeries or resulting from extended surgical requirements 
that are secondary to intraoperative findings unknown at the initiation of surgery will not be 
considered serious adverse events. 
Actions and reporting obligations in case of serious adverse events 
The investigator should take appropriate diagnostic and therapeutic measures to minimize the 
risk to the subject.   
If any SAE occurs over the course of the study, investigators or other site personnel will 
inform the Cardinal Health Drug Safety Group via phone immediately at (800) 618-2768. 
Written notification of the SAE will be faxed within one day (i.e., within 24 hours) of 


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becoming aware of the SAE to (855) 793-7501 or emailed to npssafety@cardinalhealth.com. 
For fatal or life-threatening adverse events where important or relevant information is 
missing, active follow-up is undertaken immediately. 
Pregnancy will have the same time reporting obligations to the sponsor as SAEs. Upon 
notification, Cardinal will provide a form for collection of pregnancy information. 
All SAEs must also be recorded on the Adverse Event eCRFs. 
Notification of the IRBs 
The sponsor and/or the investigator will notify the IRBs about all relevant events (e.g., 
Serious Adverse Events [SAEs] and Suspected, Unexpected, Serious Adverse Reactions 
[SUSARs]) according to all applicable regulations. 
Notification of the authorities 
The sponsor will process and report all relevant events (e.g., SAEs, SUSARs) to the 
authorities according to all applicable regulations. 
Sponsor’s notification of the investigators 
The sponsor will inform all investigators about reported relevant events (e.g., SAEs, 
SUSARs) according to all applicable regulations. 
8.7.2 
Further Safety Assessments 
8.7.2.1 
Physical Examination 
Complete physical examinations will be conducted according to the Schedule of Events (see 
Appendix 1). Any clinically significant change from baseline that results in a change in 
subject management will be considered an AE. 
Physical examination will be performed for the following body systems: 
• General appearance 
• Skin/dermatological 
• Eyes, ears, nose, throat 
• Head and neck (including thyroid) 
• Lungs 
• Heart 
• Abdomen (liver, kidney, spleen, gastrointestinal) 
• Lymph nodes 


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• Musculoskeletal 
• Nervous System 
 
8.7.2.2 
Vital Signs 
Vital signs comprise the measurement of systolic and diastolic blood pressure, body 
temperature, respiration, and heart rate. All vital signs will be measured after the subject 
should be resting quietly for 1 minute. Heart rate should be measured immediately before or 
immediately after blood pressure measurement.   
Vital signs will be measured at screening, baseline (before investigational product injection), 
10, 30, 60 minutes post injection (Day 1), and at the 4- to 14-day follow-up visit.     
Any clinically significant change from baseline that results in a change in subject 
management will be considered an AE. 
8.7.2.3 
Electrocardiogram 
A standard 12-lead ECG will be obtained at screening and on Day 1 at least 10 minutes after 
Lymphoseek injection. The ECG will be measured with the subject in a resting position for at 
least 1 minute. No continuous ECG monitoring will be required. 
On-site investigator’s responsibilities 
The immediate cardiac safety of the subject will be ensured by the on-site qualified 
physician. Any 12-lead ECG intervals, waveform abnormalities, and rhythm changes that are 
clinically significant in that they result in a change in subject management will be considered 
an AE. In the case of an SAE, once SAE notification is decided upon, investigators are 
required to follow the procedure described for SAE notification and document abnormal 
ECG findings (intervals and waveforms). Any interval data or abnormal waveform finding 
that resulted in an AE (i.e., change of patient management) must be followed for the duration 
of the subject's participation in the study until normalization or return to baseline takes place.   
Each 12-lead ECG tracing must be signed and dated and stored in the subject’s source 
documentation.   
8.8 
Other Procedures and Variables 
8.8.1 
Blood Sampling 
8.8.2 
Laboratory Data Related to Screening and Safety 
Clinical laboratory tests to be evaluated in this study include hematology, serum chemistry, 
and urinalysis. Blood and urine samples for safety will be obtained according to the Schedule 
of Events (Appendix 1) and in accordance with NIH blood volume limits. Table 10 shows the 
parameters to be assessed: 


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Table 10. 
Minimum Clinical Laboratory Parameters 
Hematology 
Hemoglobin (Hb), hematocrit (HCT),  mean corpuscular volume 
(MCV), 
mean 
corpuscular 
hemoglobin 
(MCH), 
mean 
corpuscular hemoglobin concentration (MCHC), platelets, 
neutrophils, eosinophils, basophils, lymphocytes, monocytes, red 
blood cells (RBC), RBC Morphology, white blood cells (WBC) 
Serum chemistry 
 
Aspartate aminotransferase (AST), alanine aminotransferase 
(ALT), gamma-glutamyl transferase (gamma-GT), alkaline 
phosphatase, total bilirubin, creatinine, chloride, potassium, 
sodium, total protein, albumin, globulin, Bicarbonate, blood urea 
nitrogen (BUN) 
Urinalysis 
Color, clarity, specific gravity, pH, bilirubin, glucose, ketones, 
leukocyte esterase, nitrites, protein, urobilinogen 
A central laboratory will be used for all blood and urine samples to be determined in this 
trial.   
The central laboratory will provide the necessary kits to collect the blood and urine samples 
and will also provide appropriate information regarding shipping of the samples.   
Care is to be taken not to potentially produce an erroneous value, e.g., by inappropriate use of 
the tourniquet or forceful withdrawal of blood. Each original laboratory report will be 
retained in the subject’s files.   
All laboratory reports must be promptly reviewed by the investigator, and upon review, 
initialed and dated by the investigator. Change(s) in post-dose test values considered 
clinically significant, which would require either additional control or therapy and, in case of 
disturbing or influencing factor(s) on values/samples, details of the appropriate value(s) and 
the source of disturbance or influence (e.g., quality of sample, co-medication, etc.) are to be 
recorded. Good clinical practice would suggest that a copy of the safety laboratory results be 
available to the subject and to the subject’s referring physician.   
The following are general guidelines and are provided in order to assist the investigator in 
evaluating changes in laboratory values after the administration of investigational product. 
Since from previous clinical experience, these changes are unexpected, in all instances 
laboratory error must be considered and ruled out. One common cause of error is dilution of 
the blood sample, which occurs when blood is drawn through a fluid-filled catheter.   
Changes 
in 
most 
individual 
laboratory 
values 
cannot 
be 
interpreted 
without 
concomitant/concordant changes in related parameters. For example, a decrease in hematocrit 
of approximately 5 percentage points (49% to 44%) at 24 hours post injection can be 
considered clinically significant, but without a similar change in hemoglobin and red blood 
cells (RBC), laboratory error must be ruled out. Shifts in hematocrit may also occur with 
changes in subject’s hydration status. With comparable decreases in hematocrit, hemoglobin 
and RBC, the investigator must evaluate the subject for blood loss/hemorrhage, especially at 


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the site of venipuncture. If coagulopathy or hemolysis is suspected, appropriate follow-up, 
including diagnostic tests and treatment, should be undertaken. Decreases in platelet count by 
greater than 30% of baseline value or an absolute value of less than 50,000/µL after a normal 
baseline value should also be followed up to rule out laboratory error or an underlying 
problem, such as a coagulopathy.   
Increases in 2 or more liver function and related parameters (alkaline phosphatase, AST, 
ALT, and bilirubin) that result in values twice that of the upper limit of the normal range 
must be followed up to rule out any acute liver and/or cardiac illness. The investigator must 
obtain the appropriate tests as indicated by the subject’s clinical status. Changes in sodium, 
potassium and chloride that are greater than 20% of baseline value must be followed up.   
In all instances of changes in multiple parameters, regardless of the magnitude, the 
investigator must evaluate the subject in light of the clinical signs and symptoms and institute 
appropriate treatment. There may be other abnormal laboratory changes not specifically 
noted above that the investigator may want to follow up as appropriate for a particular 
subject.   
Any change in laboratory value which results in a change in subject management (additional 
controls or treatment required) will be reported as a clinically significant change.  Clinically 
significant changes in laboratory parameters which are not the result of laboratory error are to 
be recorded as AEs. 
Any clinically significant changes in laboratory values are to be followed up with repeated 
tests at appropriate intervals (as determined by the investigator and the medical monitor) 
until the values return to baseline level or until the abnormality is explained by the 
investigator. Such additional tests should also be done at the central laboratory and will be 
entered into the database.   
The amount of blood to be withdrawn is shown in Table 11.  
Table 11. 
Amount of Blood Withdrawn 
 
Screening 
After Surgery 
Hematology 
2 to 3 mL 
2 to 3 mL 
Chemistry 
1 to 3 mL 
1 to 3 mL 
Total 
3 to 6 mL 
3 to 6 mL 
 
For subjects that weigh less than 2 kg, no more than 3 mL/kg of blood can be drawn at either 
time point. Blood and urine specimens will be sent to a central vendor for analysis. Specimen 
collection, packaging, and shipping instructions are provided in a separate laboratory manual. 


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9 
STATISTICAL METHODS  
9.1 
Introduction 
This study is a prospective, open-label study conducted at up to 10 study centers.  The 
objectives of the statistical analyses are to establish the safety and diagnostic utility of 
Lymphoseek in targeting lymphoid tissue in pediatric patients with melanoma, 
rhabdomyosarcoma, or other solid tumors who are undergoing lymph node mapping. 
A study center is defined as a treatment administration site or group of treatment 
administration sites under the control and supervision the same principal investigator. 
9.2 
Randomization Methods 
There is no randomization planned for this study. All enrolled subjects will receive 
Lymphoseek, and Lymphazurin as an optional control agent if consistent with institutional 
practice. 
9.3 
Pooling of Study Centers 
There will be no selective pooling of study centers. Subjects from all study centers will be 
pooled for the analysis. 
9.4 
Safety Variables 
9.4.1 
Primary Safety Variable 
The primary safety variable is the incidence of adverse events.   
9.4.2 
Secondary Safety Variables 
The secondary safety variables are the following: 
• Vital signs (screening, at pre- and post-injection time points, and at the 4-to 14-day 
follow-up visit)  
• Laboratory parameters (screening and after surgery) 
• ECG parameters (screening and at the post-injection time point) 
9.5 
Pharmacokinetic Variables 
Not applicable. 
9.6 
Diagnostic Variables 
9.6.1 
Primary Diagnostic Variables 
The primary diagnostic variables for this study are: 


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• Subject localization rate (defined as the proportion of subjects with Lymphoseek-
identified lymph nodes) 
• Number of lymph nodes identified intraoperatively by Lymphoseek per subject 
• Proportion of subjects who underwent preoperative SPECT or SPECT/CT 
• Proportion of subjects with a lymph nodes identified preoperatively using SPECT or 
SPECT/CT 
• Number of lymph nodes identified preoperatively using SPECT or SPECT/CT 
• Agreement of the number of nodes identified by preoperative SPECT or SPECT/CT to 
intraoperative localization 
• Subject and nodal agreement of central pathology assessment with local pathology 
assessment of the excised lymph node(s) to confirm the presence/absence of tumor 
metastases 
• Nodal false negative rate for Lymphoseek-identified nodes (using blinded central 
pathology assessment and local pathology assessment) 
• Nodal sensitivity for Lymphoseek-identified nodes (using blinded central pathology 
assessment and local pathology assessment) 
• Upstaging (defined as the proportion of patients with pathology-positive lymph nodes 
who had at least one pathology-positive lymph node that was identified by Lymphoseek 
and had no other pathology-positive lymph nodes [i.e., identified by any other method]) 
• Change in subject nodal staging before and after surgery based upon Lymphoseek-
identified nodes 
• Changes in treatment plan and relation to lymph nodes identified by Lymphoseek 
 
9.6.2 
Secondary Diagnostic Variables 
The secondary diagnostic variables for this study are for those subjects receiving both 
Lymphoseek and Lymphazurin: 
• Subject localization rate for Lymphazurin 
• Number of lymph nodes identified intraoperatively by Lymphazurin per subject 
• Nodal concordance (defined as the proportion of lymph nodes identified intraoperatively 
by Lymphazurin that are also identified intraoperatively by Lymphoseek) 
• Reverse nodal concordance (defined as the proportion of lymph nodes identified 
intraoperatively by Lymphoseek that are also identified intraoperatively by Lymphazurin) 
• Subject concordance 
• Subject reverse concordance 
• Nodal false negative rate for Lymphazurin-identified nodes (using blinded central 
pathology assessment and local pathology assessment) 
• Nodal sensitivity for Lymphazurin-identified nodes (using blinded central pathology 
assessment and local pathology assessment) 


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• Upstaging (defined as the proportion of patients with pathology-positive lymph nodes 
who had at least one pathology-positive lymph node that was identified by Lymphazurin 
and had no other pathology-positive lymph nodes (i.e., identified by any other method) 
• Change in subject nodal staging before and after surgery based upon Lymphazurin-
identified nodes 
 
9.7 
Sample Size Justification 
Approximately 27 subjects will be enrolled into the study, at least 6 of whom have been 
diagnosed with melanoma and at least 6 of whom have been diagnosed with 
rhabdomyosarcoma. Enrollment will be open to up to 15 additional subjects with other tumor 
types in which ILM and sentinel lymph node biopsy (SLNB) are appropriate. At a minimum, 
20 of the enrolled subjects will be ≤16 years of age and at least 25 subjects will complete the 
4- to 14-day follow up. The sample size was chosen in order to provide a reasonable amount 
of data to assess the safety and diagnostic performance of Lymphoseek within this limited 
pediatric subject population.   
9.8 
Handling of Missing Data 
There will be no missing value imputation used in this study. All endpoints will be analyzed 
with subjects who have non-missing data (i.e., a complete case analysis).   
9.9 
Statistical Analysis  
9.9.1 
Analysis Populations 
The following analysis populations will be defined:  
Safety: The safety population will include all enrolled subjects with administration of 
Lymphoseek. 
Intent-to-treat (ITT): The ITT population will include all protocol-eligible subjects with 
administration of Lymphoseek (with or without Lymphazurin) and complete intraoperative 
lymphatic mapping. 
Blue intent-to-treat (BITT): The BITT population will include all ITT subjects who were 
also administered Lymphazurin prior to ILM. 
Per protocol (PP): The PP population will include all ITT subjects without major protocol 
violations. 
All safety analyses will be conducted on the safety population.  The analysis of the diagnostic 
endpoints will be conducted on ITT, BITT, and PP populations, as applicable.     


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9.9.2 
Analysis of Baseline and Demographic Characteristics 
Baseline and demographic characteristics will be summarized by tumor type and overall for 
all subjects in the safety population.  Continuous variables will be displayed via summary 
statistics (mean, median, sample size, standard deviation, minimum, and maximum).  
Categorical variables will be summarized via counts and percentages. 
9.9.3 
Analysis of Primary Safety Variables 
All AEs will be observed for each subject from enrollment until termination from the study. 
Prior to analysis, all AEs will be coded using MedDRA. Based on these coded terms, AEs 
will be summarized using system organ class and preferred term by tumor type and overall 
for all subjects in the safety population. AEs will also be summarized by severity, 
relationship to investigational product, and relationship to study procedure. All AEs will be 
listed.      
9.9.4 
Analysis of Secondary Safety Variables 
Summary statistics (mean, median, sample size, standard deviation, minimum, and 
maximum) will be computed on the raw and change from baseline values for each vital sign 
parameter by time point, for each tumor type and overall. The pre-injection time point will 
serve as baseline. If there are multiple vital signs taken at any time point, then the latest set of 
vital signs will be used for the analysis. All vital sign data will be listed. 
Summary statistics (mean, median, sample size, standard deviation, minimum, and 
maximum) will be computed on the raw and change from baseline values for each 
quantitative laboratory parameter by time point, for each tumor type and overall. The 
screening time point will serve as baseline.  If there are multiple labs taken at any time point, 
then the latest set of labs will be used for the analysis.  All clinical laboratory data, including 
any qualitative urinalysis results, will be listed. 
Summary statistics (mean, median, sample size, standard deviation, minimum, and 
maximum) will be computed on the raw and change from baseline values for each ECG 
parameter by time point, for each tumor type and overall. The screening time point will serve 
as baseline. If there are multiple ECGs taken at any time point, then the latest set of ECGs 
will be used for the analysis. All ECG data will be listed. 
Additional analyses of safety variables for this study may be conducted as described in the 
Statistical Analysis Plan document. 
9.9.5 
Analysis of Primary Diagnostic Variables 
The localization rate, defined as the proportion of ITT subjects that had at least one lymph 
node identified intraoperatively, along with a 95% confidence interval will be computed for 
Lymphoseek for each tumor type and overall.   


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The average number of lymph nodes identified intraoperatively by Lymphoseek per subject, 
along with a 95% confidence interval, will be computed for each tumor type and overall.   
The proportion of ITT subjects who had preoperative SPECT performed will be summarized 
by tumor type and overall. The proportion of patients who had a hot spot on the scan will 
also be summarized by tumor type and overall. For those patients with a hot spot, the time 
from Lymphoseek injection to hot spot localization will be summarized. 
The average number of lymph nodes identified with preoperative SPECT per subject, along 
with a 95% confidence interval, will be computed for Lymphoseek by tumor type and 
overall.   
The average difference in the number of lymph nodes identified with preoperative SPECT 
per subject and the number of lymph nodes identified intraoperatively per subject, along with 
a 95% confidence interval, will also be computed. 
The nodal and subject agreement of central pathology assessment to local pathology 
assessment will be computed as follows: 
Nodal 
Agreement = 
Lymph nodes whose local and central pathology assessments were either 
both positive or both negative 
Lymph nodes with non-missing local and central pathology results 
 
Subject 
Agreement = 
 
Subjects whose local and central pathology assessments agree 
Subjects with at least one lymph node with non-missing local and central 
pathology results 
 
Where agreement on the subject level means that a subject either has at least one pathology-
positive node with local and central pathology or has all pathology-negative nodes with local 
and central pathology. For the analysis of nodal agreement and subject agreement, only 
nodes that have non-missing local and central pathology results will be considered. Along 
with the agreement proportions, a 95% confidence interval will be computed for each 
endpoint. Subgroup analyses by tumor type will also be performed within the ITT and PP 
analysis populations. 
The nodal false negative rate will be computed for Lymphoseek as the number of pathology-
positive lymph nodes that were missed intraoperatively by the tracer divided by the total 
number of pathology-positive lymph nodes. A 95% confidence interval will also be 
computed. False negative rates also will be calculated separately for the blinded central 
pathology assessment and the local pathology assessment. 
The nodal sensitivity will be computed for Lymphoseek as the number of pathology-positive 
lymph nodes identified intraoperatively by the tracer divided by the total number of 
pathology-positive lymph nodes. A 95% confidence interval will also be computed.  
Sensitivities also will be calculated separately for the blinded central pathology assessment 
and the local pathology assessment. 


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The number and proportion of subjects upstaged by Lymphoseek will be computed along 
with a 95% confidence interval, where upstaging by an individual tracer is defined as a 
subject who had at least one pathology-positive node identified by one tracer and no 
pathology-positive nodes identified by the other tracer. 
The change in subject nodal staging will be assessed via shift tables. A shift table for 
Lymphoseek will be produced to show the number of subjects with each combination of pre-
surgery and post-surgery nodal staging. Each subject’s post-surgery staging will be based on 
the pathology results of those nodes identified by Lymphoseek. For the purposes of this 
analysis, a subject may have two different post-surgery nodal staging results, one based on 
Lymphoseek-identified nodes and the other based on Lymphazurin-identified nodes (see 
Section 9.9.6).     
Changes in treatment plan and relation to lymph nodes identified by Lymphoseek will be 
listed. 
9.9.6 
Analysis of Secondary Diagnostic Variables 
The localization rate, defined as the proportion of BITT subjects that had at least one lymph 
node identified intraoperatively, along with a 95% confidence interval will be computed 
separately for Lymphazurin for each tumor type and overall.   
The average number of lymph nodes identified intraoperatively by Lymphazurin per subject, 
along with a 95% confidence interval, will be computed for each tumor type and overall.   
The nodal concordance, P1, will be computed as follows using lymph nodes from all subjects 
in the BITT population: 
P1 = Number of lymph nodes identified intraoperatively by Lymphoseek and Lymphazurin 
Number of lymph nodes identified intraoperatively by Lymphazurin 
An exact one-sided 95% confidence interval will be computed in order to test the following 
hypotheses at a one-sided α=0.05 level of significance: 
H0: P1 ≤ 0.9 vs. H1: P1 > 0.9 
If the lower boundary of the confidence interval is greater than 0.9, then the study will have 
successfully demonstrated the performance of Lymphoseek relative to the nodal concordance 
endpoint.   
Assessment as to whether lymph nodes can be considered as an independent sample will be 
evaluated using in-house and/or literature data. The details of this analysis will be described 
in the statistical analysis plan. 
Subgroup analyses by tumor type will also be performed for the BITT population, but no 
hypotheses will be tested by tumor type. 


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The reverse nodal concordance, P3, will be computed as follows using lymph nodes from all 
subjects in the BITT population: 
P3 = Number of lymph nodes identified intraoperatively by Lymphoseek and Lymphazurin 
Number of lymph nodes identified intraoperatively by Lymphoseek 
 
In addition to the above proportion, an exact one-sided 95% confidence interval will be 
computed. 
If the null hypothesis for the nodal concordance endpoint is rejected, then the following test 
of superiority of nodal concordance relative to reverse nodal concordance will be conducted 
at a one-sided α=0.05 level of significance using McNemar’s test: 
H0: P1 ≤ P3 vs. H1: P1 > P3 
If the one-sided p-value from McNemar’s test is less than 0.05, then the nodal concordance 
of Lymphoseek to Lymphazurin (P1) will be shown to be significantly greater than the 
reverse nodal concordance of Lymphazurin to Lymphoseek (P3). 
The per-subject concordance, P2, and per-subject reverse concordance, P4, will be computed 
as follows using all subjects in the BITT population: 
P2 = 
Subjects whose lymph nodes that were intraoperatively identified 
by Lymphazurin were also all identified by Lymphoseek 
Subjects with at least one lymph node intraoperatively identified by Lymphazurin 
 
and 
 
P4 = 
Subjects whose lymph nodes that were intraoperatively identified 
by Lymphoseek were also all identified by Lymphazurin 
Subjects with at least one lymph node intraoperatively identified by Lymphoseek 
 
In addition to the above proportions, exact one-sided 95% confidence intervals will be 
computed. 
The nodal false negative rate will be computed for Lymphazurin as the number of pathology-
positive lymph nodes that were missed intraoperatively by the tracer divided by the total 
number of pathology-positive lymph nodes. A 95% confidence interval will also be 
computed. False negative rates also will be calculated separately for the blinded central 
pathology assessment and the local pathology assessment. 
The nodal sensitivity will be computed for Lymphazurin as the number of pathology-positive 
lymph nodes identified intraoperatively by the tracer divided by the total number of 
pathology-positive lymph nodes. A 95% confidence interval will also be computed.  
Sensitivities also will be calculated separately for the blinded central pathology assessment 
and the local pathology assessment. 


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The number and proportion of subjects upstaged by Lymphazurin will be computed along 
with a 95% confidence interval, where upstaging by an individual tracer is defined as a 
subject who had at least one pathology-positive node identified by one tracer and no 
pathology-positive nodes identified by the other tracer. 
The change in subject nodal staging will be assessed via shift tables. A shift table for 
Lymphazurin will be produced to show the number of subjects with each combination of pre-
surgery and post-surgery nodal staging. Each subject’s post-surgery staging will be based on 
the pathology results of those nodes identified by Lymphazurin. For the purposes of this 
analysis, a subject may have two different post-surgery nodal staging results, one based on 
Lymphoseek-identified nodes and the other based on Lymphazurin-identified nodes. 
9.10 Interim Analyses 
No formal interim analyses will be conducted during this study.  
Data listings and tables of safety and diagnostic data will be created on an interim basis for 
review by a DSMC. Refer to Section 9.11 and the DSMC Charter for further details on the 
data handling and analysis procedures. 
9.11 Data and Safety Monitoring Committee 
An independent DSMC will review the interim results and make recommendations regarding 
early stopping and/or changes in the study design. Specifics of the DSMC role are detailed in 
a separate DSMC Charter. 
The first three subjects between the ages of 2 to 17 will be recruited and injected. Once these 
three subjects have completed the Day 8 safety evaluation, enrollment will be put on hold 
until the DSMC reviews all available safety information and agrees to proceed with 
additional enrollment. If the DSMC concurs, study enrollment will then be open to all age 
cohorts (1 month to <18 years). The DSMC will then determine the frequency to meet based 
on review of the available trial information. 


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10 DATA HANDLING AND QUALITY ASSURANCE 
10.1 Data Recording 
Data required according to this protocol is captured in the subject’s source documentation 
and are to be entered into the eCRFs (provided by the sponsor) as soon as possible. 
10.1.1 
Electronic CRF design 
Electronic data capture with the sponsor’s eCRF will be used for collecting all data generated 
during the study. The eCRF application has a built-in plausibility check, forcing the 
investigators to answer the questions in the appropriate manner, and auto-checks for missing 
data. The system type and eCRF details will be documented in a separate document that will 
be provided by the sponsor and maintained in the TMF. 
10.2 Monitoring 
This study will be monitored regularly by a clinical research associate (CRA) from the 
sponsor or a contract research organization (CRO). Monitoring procedures include one or 
more visits designed to clarify all prerequisites before the study starts. Interim monitoring 
visits will take place on a regular basis according to a schedule fixed by mutual agreement. 
During these visits, the CRA will check for completion of the entries on the eCRFs, their 
compliance with the protocol and with GCP, and will compare the eCRF entries with the 
source data. 
All data recorded in the eCRF will be captured in the source documentation. 
The CRA will verify the correct use of the investigational product. The investigational 
product will not be supplied to the investigator site prior to a favorable opinion from the IRB 
and the regulatory authority and, if appropriate, from the radiation protection authorities. 
In addition, the CRA will determine whether all AEs and SAEs have been appropriately 
reported (including adherence to the time periods required for SAEs). 
10.3 Data Processing 
Study data documentation will be maintained specifying all relevant aspects of data 
processing for the study (including data validation, cleaning, correcting, releasing). This 
documentation will be stored in the TMF. 
For data coding (e.g., AEs, medication, medical/surgical history), internationally recognized 
and accepted dictionaries will be used. These and the processes used for coding will be 
specified in the data management plan. 


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10.4 Auditing 
A member of the sponsor’s (or a designated CRO) quality assurance unit may arrange to visit 
the investigator in order to audit the performance of the study at the study site and the study 
documents originating there. The auditor(s) will usually be accompanied by a CRA or the 
study team lead. The investigator will be informed about the outcome of the audit. 
In addition, inspections by health authority representatives and IRB(s) are possible at any 
time. The investigator is to notify the sponsor of any such inspection immediately. 
10.5 Archiving 
Essential documents shall be archived safely and securely in such a way that ensures that 
they are readily available upon authorities’ request. 
Patient (hospital) files will be archived according to local regulations and in accordance with 
the maximum period of time permitted by the hospital, institution, or private practice.  Where 
the archiving procedures do not meet the minimum timelines required by the sponsor, 
alternative arrangements must be made to ensure the availability of the source documents for 
the required period. 
The investigator/institution notifies the sponsor if the archival arrangements change 
(e.g., relocation or transfer of ownership). 
The ISF is not to be destroyed without the sponsor’s approval. 
The investigator’s contract will contain all regulations relevant for the study center. 
10.6 Premature Termination of the Study 
Termination by the Sponsor 
The sponsor may terminate the study at a site any time for any of the following reasons: 
1. Failure to enroll subjects
2. Protocol violations
3. Inaccurate or incomplete data
4. Unsafe or unethical practices
5. Questionable safety of the investigational product
6. Suspected lack of efficacy of the investigational product
7. Administrative decision
Termination by the Investigator 
If the Investigator terminates the study prematurely, the Investigator must do the following: 
•
Return all unused investigational products and related study materials to the sponsor.


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• Provide the IRB/IEC and the sponsor with a written statement describing why the study 
was terminated prematurely. Prompt compliance with this requirement is essential so that 
the sponsor may comply with its regulatory obligations. 
 
10.6.1 
Study as a Whole 
The sponsor retains the right to prematurely terminate the study as a whole at any time.   
At the discretion of the sponsor, the entire study may be canceled for medical reasons 
(e.g., unanticipated adverse events).  In addition, the sponsor retains the right to end the study 
at any time if the study cannot be conducted as specified in the protocol.  
In case of premature termination or suspension of the study, the principal 
investigator/sponsor will promptly inform the investigator/institutions, regulatory authorities, 
and IRB of the termination or suspension and the reason for that. 
10.6.2 
Study Participant 
Individual subjects may be withdrawn from the study according to the criteria specified in 
Section 4.3. 


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11 ETHICAL AND LEGAL ASPECTS 
11.1 Ethical and Legal Conduct of the Study 
The planning and conduct of this clinical study are subject to national laws. Only when all of 
the requirements of the appropriate regulatory authority have been fulfilled will the study 
begin. The study will be conducted in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki and the ICH-GCP Guidelines of 17 Jan 1997. At the 
discretion of the investigator, the entire study may be canceled for medical reasons. In 
addition, the sponsor retains the right to end the study for medical-scientific or GCP-relevant 
reasons. In case of premature termination the investigators, IRBs and Regulatory Authorities 
will be informed by the Project Manager. As required by local law, current safety-relevant 
information will be provided to the IRB and the regulatory authorities by the sponsor. The 
sponsor will also inform all investigators about relevant safety events according to the 
applicable regulations. 
11.2 Subject Information and Consent 
All relevant information on the study will be summarized in the subject consent form and 
additionally as required by the investigator’s institution in an integrated subject information 
and consent sheet or minor assent document.  A sample informed consent form is provided as 
a document separate to this protocol. 
Based on this subject informed consent form, the investigator will explain all relevant aspects 
of the study to each subject and subject’s parent(s)/legal guardian(s), before his/her entry into 
the study (i.e., before examinations and procedures associated with selection for the study are 
performed).  
The investigator will also mention that written approval of the IRB has been obtained.  
Each subject and the subject’s parent(s)/legal guardian(s) will have ample time and 
opportunity to ask questions and will be informed about the right to withdraw from the study 
at any time without any disadvantage and without having to provide reasons for this decision.  
Following this informative discussion, the subject’s parent(s)/legal guardian(s) will be asked 
if he/she is willing to sign and personally date a statement of informed consent. Only if the 
subject’s parent(s)/legal guardian(s) voluntarily agrees to sign the informed consent form and 
has done so, may he/she enter the study. Additionally, the investigator or his/her designee 
will personally sign and date the form, too. The subject’s parent(s)/legal guardian(s) will 
receive a duplicate of the signed and dated form.  
The investigator will record in the source documentation the time and date of obtaining 
informed consent. 
In the event that informed consent is obtained on the date that baseline study procedures are 
performed, the study record or subject's clinical record must clearly show that informed 
consent was obtained prior to these procedures.  


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The informed consent form and any other written information provided to subjects and 
subject’s parent(s)/legal guardian(s) will be revised whenever important new information 
becomes available that may be relevant to the subject’s consent, or there is an amendment to 
the protocol which necessitates a change to the content of the subject information and/or the 
written informed consent form. The investigator will inform the subject of changes in a 
timely manner and will ask the subject to confirm his/her participation in the study by 
signing the revised informed consent form. Any revised written informed consent form and 
written information must receive the IRB's approval/favorable opinion in advance of use. 
11.3 Financing/Financial Disclosure 
Each investigator (including principal and/or any subinvestigators; as well as their spouses 
and dependent children) who is directly involved in the treatment or evaluation of research 
subjects has to provide a financial disclosure according to all applicable legal requirements. 
All relevant documentation will be filed in the sponsor TMF and the ISF, as appropriate. 
11.4 Publication Policy 
The sponsor will be responsible for determining when any trial results should be published. 
The sponsor will work jointly with the investigator(s) to publish information in a timely 
manner. The investigator(s) shall not submit any information gleaned under the direct 
support or sponsorship of the sponsor to journals or professional societies without the prior 
written approval of the sponsor. A "publication" is meant to include any abstract, letter, 
manuscript or public announcement in any form or length that contains information gleaned 
under the direct support or sponsorship of the sponsor. 
11.5 Subject Injury 
In general, if a subject is injured as a direct result of the investigational product but not due to 
medical negligence on the part of the principal investigator or study staff, the sponsor will 
pay for reasonable and necessary medical treatment for the injury, to the extent the expenses 
are not covered by the subject’s medical insurance, a government program, or other 
responsible third party. If laws or regulations of the locality in which the trial is taking place 
require additional payment of expenses, the sponsor shall comply with such law or 
regulation. Where applicable, the sponsor will provide electronic evidence of insurance. 


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Appendix 1 
Schedule of Events 
 
Assessment 
Screen 
(Day -29 to 
Day 0) 
Pre- and Post-Injection 
Day 1 
(hour: minute relative to Lymphoseek injection) 
Safety 
Follow-up 
(4 to 14 
days; in 
person) 
Before 
Injection 
0:00 
00:10 
0:30 
1:00 
Surgery 
After 
Surgery 
Informed Consent 
X 
 
 
 
 
 
 
 
 
Entry Criteria  
X 
 
 
 
 
 
 
 
 
Medical History and 
Demography 
X 
 
 
 
 
 
 
 
 
Performance Status 
X 
 
 
 
 
 
 
 
 
Cancer Staging 
X 
 
 
 
 
 
 
 
X 
Vital Signsa 
X 
X 
 
X 
X 
X 
 
 
X 
ECG 
X 
 
 
X 
 
Physical Examination 
X 
 
 
 
 
 
 
 
X 
Review of Medications 
X 
 
 
 
 
 
 
X 
X 
Collect Blood and Urine for 
Central Labb  
X 
 
 
 
 
 
X 
 
Urine or Serum Pregnancy Testc 
X 
 
 
 
 
 
 
 
Lymphoseek Administration 
 
 
X 
 
 
 
 
 
 
Lymphoscintigraphy 
SPECT/CTd 
 
 
X 
 
 
 
Lymphazurin Administratione 
 
 
 
 
 
 
X 
 
 
Surgery and SLNBf 
 
 
 
 
 
 
X 
 
 
Treatment Plan 
 
 
 
 
 
 
 
 
X 
Adverse Event Monitoring 
 
X 
X 
X 
X 
X 
X 
X 
X 
a Body weight and height will only be collected at screening 
b Blood and urine may be collected on Day 1 if performed before Lymphoseek injection 
c Pregnancy testing should be performed within 48 hours before Lymphoseek injection 
d Imaging may begin at the time of injection when performing dynamic imaging  STATIC planar imaging should begin approximately 15 minutes post injection  
e When used, vital blue dye will be administered at the start of or during surgery in accordance with the standard of care at the clinical site 
f Surgery, node probing, and harvesting should occur between 15 minutes and 8 hours after Lymphoseek injection 


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Appendix 2 
Gamma Detector Counts Calculation Sheet 
  






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Appendix 4 
Investigator’s Signature 
Study Title: 
A Prospective, Open-Label, Multicenter Study of Lymphoseek® 
as a Lymphoid Tissue Targeting Agent in Pediatric Patients With 
Melanoma, Rhabdomyosarcoma, or Other Solid Tumors Who 
Are Undergoing Lymph Node Mapping 
Study Number: 
NAV3-18 
Original Protocol Date: 
24 April 2015 
Amendment 1 Date: 
14 August 2015 
Amendment 2 Date: 
18 January 2016 
Amendment 3 Date: 
11 January 2017 
Amendment 4 Date: 
01 September 2017 
I have read the protocol described above. I agree to comply with all applicable regulations 
and to conduct the study as described in the protocol. 
 
 
Signed: 
 
 
Date:  
 
<enter name and credentials> 
<enter title> 
<enter affiliation> 
<enter address> 
<enter phone number> 
 
 
 

ICF_001.pdf: