Clinical trial NCT02112656
Conditions: Hepatocellular Carcinoma
Keywords: Carcinoma Carcinoma, Hepatocellular Neoplasms, Glandular and Epithelial Neoplasms by Histologic Type Neoplasms Adenocarcinoma Liver Neoplasms Digestive System Neoplasms Neoplasms by Site Digestive System Diseases Liver Diseases Doxorubicin Antibiotics, Antineoplastic Antineoplastic Agents Therapeutic Uses Pharmacologic Actions
Sponsor: Imunon
Start date: 2014-06-01; Completion date: 2020-04-27
Enrollment: 554 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The purpose of this study is to determine whether ThermoDox, a thermally sensitive liposomal doxorubicin, is effective in the treatment of non-resectable hepatocellular carcinoma when used in conjunction with standardized radiofrequency ablation (sRFA).

Detailed description:
This is a Phase III, randomized, double blind, dummy controlled safety and efficacy study of ThermoDox plus sRFA compared to sRFA plus dummy infusion using standardized treatment dwell time for solitary HCC lesions ≥ 3.0 cm to ≤ 7.0 cm. An sRFA treatment for this protocol is defined as the dwell time of ≥ 45 minutes measured from the first activation of the RFA probe through removal of the RFA probe after the final ablation cycle or deployment.

The 50 mg/m2 ThermoDox or dummy infusion will be administered IV over 30 minutes. As part of blinded pre-medication ThermoDox treated subjects will receive 20 mg of dexamethasone orally 24 hours prior to the drug infusion for infusion reaction prophylaxis. Subjects on the control arm will receive a matching dummy pre-medication pill orally at 24 hours prior to infusion of the study treatment. Thirty minutes prior to receiving the ThermoDox infusion, subjects will receive a blinded dose of 20 mg of IV dexamethasone, 50 mg IV diphenhydramine and either 50 mg of IV ranitidine or 20 mg of IV famotidine. Subjects on the control arm will receive a masked dummy pre-medication pill orally at 24 hours prior to infusion of the study medication, and a dummy infusion 30 minutes prior to dummy infusion of Sodium Chloride 0.9% or 5% Dextrose (D5W). RFA will be initiated approximately at a minimum of 15 minutes after the initiation of study drug infusion and should be completed no later than 3 hours after study drug infusion initiation. The goal is to reach a \> 45 minute dwell time which can be achieved by employing at least four ablation cycles or deployments in order to ablate the tumor as well as a 360º 1.0 cm tumor-free margin surrounding the tumor.with an estimated overall procedure time of less than 3 hours.

A subject who has an incomplete ablation is eligible for 1 retreatment procedure within 21 days after the radiological imaging exam showing residual disease at Day 28. Subjects will be retreated only once with the same RFA equipment and treatment assigned at randomization. Subjects with a complete ablation after retreatment will be followed both for PFS and for OS.

If after 2 ablations the subject has local, distant intrahepatic, or extrahepatic HCC, then the subject will be considered a treatment failure and will have met the PFS endpoint. The subject will be followed for OS every 3 months. Among subjects who are not treatment failures, five repeat treatments are permitted to treat a recurrent lesion or to treat newly-identified local or distant intrahepatic lesions at the Investigator's discretion after the PFS endpoint is reported and with agreement from the Sponsor. The subject must be eligible for retreatment consistent with the safety eligibility criteria and will be retreated with the same randomized treatment.

CT or MRI imaging will be used to assess the effectiveness of the ablation therapy. The blind will be maintained at the level of the imaging reads. Investigator determined radiological progression must be observed and recorded prior to beginning alternate treatments for HCC. Posttreatment imaging will be obtained at months 1, 5, 9, 13, 17, 21, 25, then every 6 months (+/- 2 weeks) until radiological progression is seen. Adverse event assessments and laboratory examinations will occur at each visit. All subjects will be monitored throughout the investigational period.

Patients that meet inclusion/exclusion criteria may be at risk for contrast-induced nephropathy (CIN) when undergoing the required CT with contrast procedures. The investigators must be mindful of the risk factors associated with CIN and employ strategies to reduce the risk of CIN. In subjects with diabetes or borderline renal function (creatinine greater than 1.5 mg/dL) special precautions (e.g. hydration, contrast dose reduction, follow up creatinine determination) should be employed. An accepted procedure is adequate intravenous volume expansion with isotonic saline (1.0 - 1.5 mL/kg per hour) for 3-12 hours before the procedure and continued for 6-24 hours if clinically indicated and based on the treating physician's medical judgment.

All randomized subjects will be followed for safety and overall survival.

Arms: arm 1: ThermoDox plus standardized RFA using standardized treatment dwell time for solitary HCC lesions ≥ 3.0 cm to ≤ 7.0 cm arm 2: standardized RFA alone using standardized treatment dwell time for solitary HCC lesions ≥ 3.0 cm to ≤ 7.0 cm
Interventions: intervention 1: ThermoDox intervention 2: Dummy infusion
Intervention descriptions: intervention 1: Thermally Sensitive Liposomal Doxorubicin 50 mg/m2 Single 30 minute intravenous infusion intervention 2: Sodium Chloride 0.9% or 5% Dextrose (D5W), Single 30 minute intravenous infusion

Protocol documents:
Prot_000.pdf: 
 
Celsion Corporation 
 
XXXXXXXXXX 
 
CLINICAL PROTOCOL 1 
 
 
Study Title: 
A Phase III, Randomized, Double Blind, Dummy-Controlled Study 
of ThermoDox® (Lyso-Thermosensitive Liposomal Doxorubicin-
LTLD) in Hepatocellular Carcinoma (HCC) using standardized 
Radiofrequency Ablation (RFA) treatment time ≥ 45 minutes for 
solitary lesions ≥ 3 cm to ≤ 7 cm. 
 
Protocol Number: 
104-13-302 
 
Protocol Version/Date: 
Version 2.0, 14-March-2014    
 
Prior Versions/Date:  
Version 1.0, 13-January-2014 
 
Investigational Product: 
ThermoDox® (Lyso-Thermosensitive Liposomal Doxorubicin) 
 
Development Phase: 
3 
 
Sponsor: 
Celsion Corporation 
997 Lenox Drive, Suite 100 
Lawrenceville, NJ  08648  USA 
 
IND Number: 
66,827 
 
EudraCT Number:  
2014-000934-53   
 
NCT Number: 
02112656 
 
 
 
 
 
 
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LIST OF STUDY REPRESENTATIVES 
The list of organizations below have responsibilities for oversight and conduct of the clinical study 
that will be identified in a transfer of responsibility document. Contact details are consistent at the 
time of the final protocol.  
 
Sponsor 
Celsion Corporation 
997 Lenox Drive Suite 100 
Lawrenceville, NJ 08648 
Phone: XXXXXXXXXX            Fax: (XXXXXXXXXX0 
Sponsor Medical Expert XXXXXXXXXX  
Celsion Corporation 
Senior Vice President and Chief Medical Officer 
Phone: XXXXXXXXXX 
Medical Monitor 
Representatives 
Asia Pacific 
Accelovance  
XXXXXXXXXX. 
XXXXXXXXXX 
Phone: XXXXXXXXXX  
Europe/North America 
Drug Safety Solutions 
XXXXXXXXXX. 
XXXXXXXXXX  
Phone: XXXXXXXXXX 
SAE Reporting 
InVentiv Pharmacovigilance- Fax Reporting 
North America 
Mainland China 
Europe and ROW 
XXXXXXXXXX 
XXXXXXXXXX 
XXXXXXXXXX 
Organization 
Responsible for 
Monitoring Trial 
InVentiv Health Clinical 
504 Carnegie Center 
Princeton, NJ 08540        
USA   
Telephone: XXXXXXXXXX               Fax: XXXXXXXXXX 
EU Legal 
Representation 
PharmaNet Ltd 
Thames House 
17-19 Marlow Road 
Berkshire SL6 7AA 
United Kingdom 
 


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Investigational Product 
Supplier 
Sharp Clinical Supply Packaging        Sharp Clinical Distribution 
300 Kimberton Road                           1041 W. Bridge Street 
Phoenixville, PA 19460                       Phoenixville, PA 19460 
USA 
USA 
Telephone: XXXXXXXXXX 
Administrative changes during the study may not require amendment to the protocol. Future changes 
will be recorded in the transfer of responsibility document. 
 
Coordinating Investigators 
 
Mainland China 
Chen Min Hua, M.D. 
Beijing University Cancer Hospital 
No. 52 FuCheng Road 
Haidian District 
Beijing, 100142, People’s Republic of China 
Asia/ Pacific 
Ronnie T. Poon, M.D. 
The University of Hong Kong, Dept. of Surgery 3/F Block L 
Queen Mary Hospital 
102 Pokfulam Road 
Hong Kong, People’s Republic of China 
Europe  
 
Riccardo Lencioni, M.D. 
Ospedale Cisanello, University of Pisa 
Via Paradisa, 2 
Pisa 56124, Italy 
Responsible 
Investigators and 
Laboratories 
FDA Form 1572 will capture list of Responsible Investigator’s 
and Laboratories utilized for the trial. 


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RATIONAL FOR AMENDMENT CHANGES 
 
Protocol Version 1.0 13-January-2014 to Version 2.0, 14-March-2014 
 
Overview of Changes 
The protocol amendment is issued to address regulatory comments received on 4-Mar-2014 
from U.S. FDA.  The overview of the changes include 
1. 
Minor edits to the inclusion criteria to further characterize the RFA procedure 
duration ≥ 45 minutes and to the exclusion criteria increasing baseline platelet level 
counts to 75,000/mm3 
2. 
Standardize follow up visits to evaluate safety and PFS at consistent intervals. 
3. 
Provide further guidance for consistency in reporting investigator determined PFS 
definitions in Section 12.0. 
4. 
Administrative changes made throughout the protocol may not be detailed in 20.10 of 
changes 
A table listing the changes in each protocol section is detailed in Appendix X of the protocol.  
 
 
 


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STATEMENT OF COMPLIANCE 
 
The procedures set out in this study protocol are designed to ensure that Celsion and 
Investigator abide by the principles of the Guideline for Good Clinical Practice (GCP) of the 
International Conference on Harmonisation (ICH) and the Declaration of Helsinki in the 
conduct, evaluation and documentation of this study, required by the following: 
• United States (US) Code of Federal Regulations (CFR) applicable to clinical 
studies (45 CFR Part 46; 21 CFR Part 50, 21 CFR Part 56, and 21 CFR Part 312). 
• EU Directive 2001/20EC of April 2001, in those countries where the directive is 
fully implemented 
 
Before the start of the study, the study protocol, written informed consent form(s) and/or 
other appropriate documents will be submitted to the Independent Ethics Committee and/or 
the authorities, in accordance with local legal requirements. 
 
In addition, any advertising materials must be approved by Celsion Clinical Affairs and an 
Independent Ethics Committee before use. The study will be conducted in accordance with 
US FDA, applicable national and local health authorities and the IEC requirements. 
 
All study personnel are required to have proper training on study procedures and GCP 
guidelines on protection of subject interests, health and confidentiality. 
 
 
 
 
 
 
 
 
 
 


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SIGNATURE PAGE FOR SPONSOR 
 
IND No. 66,827 
Study No. 104-13-302 
Title: A Phase III, Randomized, Double Blind, Dummy-Controlled Study of 
ThermoDox® (Lyso-Thermosensitive Liposomal Doxorubicin-LTLD) in Hepatocellular 
Carcinoma (HCC) using standardized Radiofrequency Ablation (RFA) treatment time 
≥ 45 minutes for solitary lesions ≥ 3 cm to ≤ 7 cm. 
 
This study protocol was reviewed internally and with Medical consultants and has been 
approved by the appropriate study protocol review committee.  The information it contains is 
consistent with: 
 
1. 
Investigator's Brochure with details of pharmacological and toxicological findings 
with the Investigational Product, and 
 
2. 
The moral, ethical and scientific principles governing clinical research as set out 
in the Declaration of Helsinki and Good Clinical Practice guidelines. 
The Investigator will be supplied with details of any significant or new findings, including 
adverse events.   
 
Approved by the following: 
 
XXXXXXXXXX 
Senior Vice President and Chief Medical Officer 
Celsion Corporation 
997 Lenox Drive, Suite 100 
Lawrenceville, NJ  08648  USA 
 
 
 
 
 
 
 
 
 
Signature 
 
 
Date 


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SIGNATURE PAGE FOR INVESTIGATOR 
 
IND No. 66,827 
Study No. 104-13-302 
Title: A Phase III, Randomized, Double Blind, Dummy-Controlled Study of ThermoDox® 
(Lyso-Thermosensitive Liposomal Doxorubicin-LTLD) in Hepatocellular Carcinoma (HCC) 
using standardized Radiofrequency Ablation (RFA) treatment time ≥ 45 minutes for solitary 
lesions ≥ 3 cm to ≤ 7 cm. 
 
I have carefully read this protocol and agree that it contains all the necessary information 
required to conduct the study.  I agree to conduct this study as outlined in the protocol. 
1. 
I understand that this study will not be initiated without approval of the appropriate 
Institutional Review Board/Research Ethics Board/Independent Ethics Committee 
(IRB/REB/IEC), and that all administrative requirements of the governing body of the 
Institution will be complied with fully. 
2. 
Informed written consent will be obtained from all participating subjects in 
accordance with institutional guidelines, FDA requirements as specified in Title 21 
CFR, Part 50, the European Union Directive 2001/20/EC and its associated Detailed 
Guidances, the ICH Guideline for Good Clinical Practice, and the terms of the 
Declaration of Helsinki. 
3. 
I will enroll subjects who meet the protocol criteria for entry. 
4. 
I understand that I am responsible for medical supervision during the conduct of this 
protocol. 
5. 
I understand that my signature on each completed Case Report Form indicates that I 
have carefully reviewed each page and accept full responsibility for the contents 
thereof. 
6. 
I understand that the information presented in this study protocol is confidential, and I 
hereby assure that no information based on the conduct of the study will be released 
without prior consent from the Sponsor unless this requirement is superseded by the 
Food and Drug Administration, a Competent Authority of the European Union, China 
Food and Drug Administration or another Regulatory Authority. 
 
 
Investigator Name 
  
Signature  
 
 
Date 
 
Investigator Position  
 
Investigator Address  
 
  


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 Table of Contents 
 
List of Study Representatives .................................................................................................2 
RATIONAL FOR AMENDMENT CHANGES ....................................................................4 
STATEMENT OF COMPLIANCE .......................................................................................5 
SIGNATURE PAGE FOR SPONSOR ..................................................................................6 
SIGNATURE PAGE FOR INVESTIGATOR ......................................................................7 
Table of Contents .....................................................................................................................8 
1. PROTOCOL SYNOPSIS ..................................................................................................12 
2. LIST OF ABBREVIATIONS ...........................................................................................19 
3. INTRODUCTION..............................................................................................................22 
3.1 
OVERVIEW ................................................................................................................22 
3.2 
RADIOFREQUENCY ABLATION (RFA) .......................................................................22 
3.3   
THERMODOX ............................................................................................................24 
4. OBJECTIVES ....................................................................................................................25 
4.1 
PRIMARY OBJECTIVE ................................................................................................25 
4.1.1 
Measurement of the Primary Objective .......................................................... 25 
4.2 
SECONDARY OBJECTIVES ..........................................................................................26 
4.2.1 
Measurement of Secondary Objectives .......................................................... 26 
5. STUDY PLAN ....................................................................................................................27 
5.1 
DESIGN OVERVIEW ...................................................................................................27 
5.2 
TRIAL TERMINATION ................................................................................................30 
6. STUDY POPULATION ....................................................................................................30 
6.1 
SOURCE AND NUMBER OF SUBJECTS .........................................................................30 
6.2 
SUBJECT SELECTION CRITERIA .................................................................................30 
6.2.1 
Overview ......................................................................................................... 30 
6.2.2 
Inclusion Criteria ............................................................................................ 30 
6.2.3 
Exclusion Criteria ........................................................................................... 31 
6.2.4 
Potential Risks and Benefits ........................................................................... 32 
7. ENROLLMENT AND WITHDRAWAL PROCEDURES ............................................35 
7.1 
ENROLLMENT PROCEDURES ......................................................................................35 
7.2 
SUBJECT DISCONTINUATION .....................................................................................35 
7.3 
STUDY NONCOMPLIANCE ..........................................................................................36 
7.4 
END OF THE STUDY ...................................................................................................36 
8. STUDY TREATMENT ADMINISTRATION ................................................................36 
8.1 
ALLOCATION TO TREATMENT ...................................................................................36 
8.2 
PRE-MEDICATION AND THERMODOX ADMINISTRATION...........................................36 
8.3 
USE OF RADIOFREQUENCY ABLATION DEVICES .......................................................38 
8.4 
RADIOFREQUENCY ABLATION PROCEDURE ..............................................................38 
8.5 
DOSE MODIFICATIONS ..............................................................................................40 


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8.5.1 
Hepatobiliary Surveillance.............................................................................. 40 
8.5.2 
Suggested Management for Hypersensitivity Reactions: ............................... 40 
8.5.3 
Extravasations ................................................................................................. 40 
8.5.4 
Dose Modification for Re-Treatment ONLY ................................................. 40 
9. STUDY MEDICATION ....................................................................................................41 
9.1 
CLINICAL SUPPLIES ...................................................................................................42 
9.2 
PACKAGING AND LABELING ......................................................................................42 
9.3 
STORAGE OF STUDY MEDICATION ............................................................................43 
9.4 
THAWING, STABILITY, AND RECONSTITUTION OF THERMODOX ...............................43 
9.5 
DRUG ACCOUNTABILITY/DISPOSITION OF CLINICAL TRIAL SUPPLIES ......................43 
10. SCHEDULE OF STUDY PROCEDURES .................................................................44 
10.1 
STUDY PROCEDURES .................................................................................................47 
10.1.1 
Screening Overview ........................................................................................ 47 
10.1.2 
Subject Numbering ......................................................................................... 47 
10.1.3 
Demographics and Medical History ............................................................... 47 
10.1.4 
Disease History and Biopsy ............................................................................ 47 
10.1.5 
Physical Exam ................................................................................................. 48 
10.1.6 
Vital Signs ....................................................................................................... 48 
10.1.7 
ECOG Performance Status ............................................................................. 49 
10.1.8 
Imaging ........................................................................................................... 49 
10.1.9 
ECG................................................................................................................. 49 
10.1.10 ECHO/MUGA Scan for LVEF Monitoring .................................................... 50 
10.1.11 Serum Pregnancy Test .................................................................................... 50 
10.1.12 Laboratory Analytes........................................................................................ 50 
10.2 
RE-TREATMENT ........................................................................................................51 
10.3 
UNSCHEDULED ASSESSMENTS AND EARLY DISCONTINUATION ................................51 
11. CONCOMITANT MEDICATIONS ...........................................................................52 
12. ASSESSMENT OF EFFICACY ..................................................................................53 
12.1 
PRIMARY ENDPOINT: SURVIVAL ...............................................................................53 
12.2 
SECONDARY ENDPOINT: PROGRESSION FREE SURVIVAL ..........................................53 
12.3 
BASELINE ASSESSMENT ............................................................................................53 
12.4 
TARGET LESION RESPONSE AND LOCAL RECURRENCE .............................................54 
12.4.1 
Response Criteria for Assessing Index Lesion ............................................... 54 
13. ASSESSMENT OF SAFETY .......................................................................................57 
14. ADVERSE EVENTS ....................................................................................................57 
14.1 
LABORATORY TEST RESULTS ...................................................................................58 
14.2 
OVERDOSE ................................................................................................................59 
14.3 
NON-SERIOUS CLINICAL ADVERSE EVENTS..............................................................59 
14.4 
SERIOUS ADVERSE EVENTS (SAE) ...........................................................................59 
14.4.1 
Definition of Life-Threatening Adverse Experiences ..................................... 60 
14.4.2 
Definition of Disabling/Incapacitating Experiences ....................................... 60 
14.4.3 
Reporting of SAEs .......................................................................................... 60 
14.5 
OTHER EVENTS .........................................................................................................62 


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15. STATISTICS .................................................................................................................62 
15.1 
STUDY POPULATIONS ................................................................................................62 
15.2 
STUDY ENDPOINTS ....................................................................................................62 
15.2.1 
Primary Endpoint – Overall Survival (OS) ..................................................... 62 
15.2.2 
Secondary Endpoints ...................................................................................... 63 
15.2.2.1 
Progression-Free Survival (PFS) ............................................................ 63 
15.3 
STATISTICAL ANALYSIS ............................................................................................63 
15.3.1 
Subject Disposition, Baseline and Treatment Characteristics ........................ 63 
15.3.1.1 
Subject Disposition ................................................................................. 63 
15.3.1.2 
Subject Baseline Characteristics ............................................................. 63 
15.3.1.3 
Study Treatment ...................................................................................... 63 
15.3.1.4 
Non-Study Treatment in the Study Follow-up Period ............................ 63 
15.3.2 
Efficacy Analyses ........................................................................................... 63 
15.3.2.1 
Primary Efficacy Analysis ...................................................................... 63 
15.3.2.2 
OS - Supportive Analyses ....................................................................... 64 
15.3.2.3 
Secondary Endpoint Analyses ................................................................ 64 
15.3.2.4 
Safety Analyses ....................................................................................... 65 
15.4 
DETERMINATION OF SAMPLE SIZE ............................................................................65 
15.4.1 
Study Population ............................................................................................. 65 
15.5 
INTERIM ANALYSES ..................................................................................................65 
16. DATA HANDLING ......................................................................................................66 
16.1 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ......................................................66 
16.2 
QUALITY CONTROL AND QUALITY ASSURANCE .......................................................66 
16.2.1 
Monitoring of the Study and Regulatory Compliance .................................... 66 
16.2.2 
Curricula Vitae and Financial Disclosure of Investigators ............................. 67 
16.2.3 
Protocol Modifications.................................................................................... 67 
16.3 
DATA HANDLING AND RECORD KEEPING .................................................................67 
16.3.1 
Data Collection ............................................................................................... 68 
16.3.2 
Recording of Data ........................................................................................... 68 
16.3.3 
Study Records ................................................................................................. 68 
16.4 
FINANCING AND INSURANCE .....................................................................................68 
16.5 
PUBLICATION POLICY ...............................................................................................69 
17. ETHICAL CONSIDERATIONS .................................................................................69 
17.1 
INFORMED CONSENT .................................................................................................70 
17.2 
INSTITUTIONAL REVIEW BOARD/RESEARCH ETHICS BOARD/INDEPENDENT 
ETHICS COMMITTEE ..................................................................................................70 
17.3 
SUBJECT PROTECTION ...............................................................................................70 
17.3.1 
Subject Privacy ............................................................................................... 70 
17.3.2 
Rationale for Subject Selection ....................................................................... 71 
17.3.3 
Participation of Children ................................................................................. 71 
18. TRIAL ADMINISTRATIVE INFORMATION ........................................................71 
18.1 
PROTOCOL AMENDMENTS .........................................................................................71 
19. REFERENCES ..............................................................................................................72 


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20. APPENDICES ...............................................................................................................75 
20.1 
APPENDIX I: CHILD-PUGH CLASSIFICATION OF HEPATIC IMPAIRMENT .....................75 
20.2 
APPENDIX II: NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL 
CLASSIFICATION FOR HEART FAILURE ......................................................................76 
20.3 
APPENDIX III: PROHIBITED MEDICATIONS ................................................................77 
20.4 
APPENDIX IV: RFA TREATMENT PROCEDURE ..........................................................79 
20.5 
APPENDIX V: ADVERSE EVENTS (AES) AND CRITERIA FOR DETERMINING 
RELATIONSHIP OF AE TO TREATMENT ......................................................................80 
20.6 
APPENDIX VI:  ECOG PERFORMANCE STATUS .........................................................82 
20.7 
APPENDIX VII: REQUIREMENTS OF WRITTEN INFORMED CONSENT DOCUMENT 
(21 CFR 50.20 AND 50.25 AND ICH GCP, TOPIC E6, SECTION 4.8) .........................83 
20.8 
APPENDIX VIII: AASLD DIAGNOSTIC CRITERIA ......................................................85 
20.9 
APPENDIX IX: LINK TO THE MOST RECENT VERSION OF NCI COMMON TOXICITY 
CRITERIA FOR ADVERSE EVENTS (CTCAE), VERSION 4...........................................87 
20.10 APPENDIX X: DESCRIPTION OF AMENDMENT CHANGES ...........................................88 
 
 


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1. PROTOCOL SYNOPSIS 
Title of Study 
A Phase III, Randomized, Double Blind, Dummy-Controlled Study of ThermoDox® 
(Lyso-Thermosensitive Liposomal Doxorubicin-LTLD) in Hepatocellular Carcinoma 
(HCC) using standardized Radiofrequency Ablation (RFA) treatment time ≥ 45 
minutes for solitary lesions ≥ 3 cm to ≤ 7 cm. 
Protocol Number 
104-13-302 
Countries 
Global 
Study Centers 
Up to 100 Centers 
Study Period 
Approximately 36-month enrollment with estimated 5-year follow up 
Clinical Phase 
Phase III 
Objectives 
The primary objective is to compare overall survival (OS) between patients receiving 
RFA plus ThermoDox versus RFA alone, using a standardized Radiofrequency 
Ablation (sRFA) treatment dwell time ≥ 45 minutes. 
 
The secondary objectives are to compare progression-free survival (PFS) and safety 
between patients receiving sRFA plus ThermoDox versus sRFA alone, using a 
standardized treatment dwell time ≥ 45 minutes. 
Study Design  
This is a randomized, double blind, dummy controlled multicenter trial to evaluate 
the efficacy and safety of ThermoDox plus sRFA compared to sRFA alone using 
standardized treatment dwell time ≥ 45 min. for solitary HCC lesions ≥ 3.0 cm to 
≤7.0 cm. An sRFA treatment for this protocol is defined as the dwell time of ≥ 45 
minutes measured from the first activation of the RFA probe to produce coagulative 
necrosis of target tissue through removal of the RFA probe after the final ablation 
cycle or deployment. This includes the multiple ablation cycles and repositioning 
time between cycles for an individual patient. 
 
Eligible HCC patients will have a solitary lesion not amenable to curative resection 
consistent with clinical diagnosis of AASLD classification guidelines and will be 
candidates for RFA. Subjects will be randomly assigned to receive either 
standardized sRFA plus ThermoDox at 50 mg/m2 or standardized sRFA plus a 
dummy infusion using a standardized RFA dwell time ≥ 45 minutes. Randomization 
and analysis will be stratified by maximum lesion diameter (3-5 cm versus > 5-7 
cm) and RFA route (laparoscopic, open surgical, percutaneous). 
 
Screening Period  
Subjects will be evaluated up to 21 days prior to the RFA procedure date to 
establish eligibility for study treatment. Subjects must meet all the study 
inclusion/exclusion criteria prior to randomization to a treatment arm.  


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Treatment Period 
Subjects who meet the eligibility criteria will be randomly assigned to either sRFA 
plus ThermoDox or sRFA plus dummy infusion using a web-based randomization 
system. The RFA procedure day will be Day 0 and subjects will return to the clinic 
Day 14 and Day 28 (+/- 3 days). Subjects with a complete ablation by imaging will 
continue in the follow up period described below.   
 
A subject who has an incomplete ablation is eligible for 1 retreatment procedure 
within 21 days after radiological imaging exam showing residual disease at Day 28. 
Subjects will be retreated only once with the same RFA equipment and treatment 
assigned at randomization. Baseline safety evaluations must meet the eligibility 
parameters prior to a retreatment. Subjects with a complete ablation after 
retreatment will be followed for both overall survival (OS) and progression-free 
survival (PFS). If after 2 ablations the subject has local, distant intrahepatic, or 
extrahepatic HCC, then the subject will be considered a treatment failure and will 
have met the PFS endpoint. The subject is still followed for OS every 3 months after 
progression.   
 
Among subjects who are not treatment failures, up to five repeat treatments are 
permitted to treat a recurrent lesion or to treat newly identified local or distant 
intrahepatic lesions at the Investigator’s discretion after the PFS endpoint is reported 
and with agreement from the Sponsor. The subject must be eligible for retreatment 
consistent with the safety eligibility criteria and will be retreated with the same 
randomized treatment. 
 
Follow up visits are performed Day 14 and Day 28 (+/- 3 days) following the 
treatment. Subjects with bilirubin levels > 2.0 mg/dL and ≤ 3.0 mg/dL will return to 
the clinic on Day 7 for additional safety assessments. Exclusion concomitant 
medications are to be restricted through Day 28 following study treatment.  
 
Follow-Up Period 
 
Following study treatment, subjects will undergo CT or MRI imaging scans (chest, 
abdomen, and pelvis)  at months 1, 5, 9, 13, 17, 21, and 25 (+/- 2 weeks), then at 6-
month intervals (+/- 2 weeks) until radiological progression is seen. The same 
imaging modality and measurement of assessment should be used to characterize 
disease at baseline and during follow up for an individual patient. Investigator 
determined radiological progression must be observed and recorded prior to 
beginning alternate treatments for HCC. Post-progression treatments will be 
reported and the subject will continue to be followed for OS.  
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the 
following additional safety assessments will be done: 
• 
Physical examination, assessment of vital signs, ECGs, CBC with differential, 
serum chemistry, PT/INR and urinalysis at Month 5, Month 9, and Month 13 
(+/- 2 weeks) or at disease progression, whichever occurs first. 
• 
LVEF monitoring at Month 13 or at disease progression, whichever occurs 
first. 
• 
Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 
25 (+/- 2 weeks) or at disease progression, whichever occurs first. 


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The site will contact all subjects every 3 months after radiological progression to 
document vital status until the subject expires or withdraws consent from the study. 
The follow-up contacts across all clinical sites may be coordinated using the same 
3-month interval.  
 
Inclusion Criteria 
Subjects must meet all of the following criteria to be eligible for the study:  
1. Male or female ≥ 18 years of age. 
2. Diagnosed with a single HCC lesion ≥ 3.0 cm but ≤ 7.0 cm in maximum  
diameter based on diagnosis at screening.  
• 
Subjects meeting the American Association for the Study of Liver Disease 
(AASLD) criteria may be randomized without a biopsy, but will undergo a 
biopsy during the RFA procedure unless contraindicated or unattainable. 
• 
Subjects not meeting the AASLD criteria for HCC will need a biopsy to 
confirm HCC prior to randomization. 
3. Be an appropriate candidate for receiving RFA as a medically indicated 
treatment as evaluated by the following factors: 
• 
The position and accessibility of the target lesion allows for the safe 
administration of multiple ablation cycles or deployments to achieve a probe 
dwell time of ≥ 45 minutes.  
• 
Not a candidate for surgical resection according to the local guidelines for 
resection and in the Investigator’s judgment. 
4. Child-Pugh Class A without either current encephalopathy or ascites. 
5. Left Ventricular Ejection Fraction (LVEF) ≥ 50%. 
6. ECOG performance status 0. 
7. Willing to sign an informed consent form, indicating awareness of the 
investigational nature of this study that is in keeping with the policies of the 
institution. 
Exclusion 
Criteria 
 
Subjects meeting any of the following criteria will be excluded from the study:  
1. 
Is scheduled for liver transplantation  
2. 
Expected ablation volume > 30% of total liver volume or removal of 3 hepatic 
segments 
3. 
More than 1 lesion identified during baseline.  
4. 
Have previously received therapeutic treatment for HCC outside the study 
protocol or is expected to receive concomitant HCC treatment prior to PFS 
event. 
5. 
Have serious medical illnesses including, but not limited to, congestive heart 
failure, myocardial infarction or cerebral vascular accident within the last six 
months, or life threatening cardiac arrhythmias. 
6. 
Have previously received any  anthracycline outside the protocol  
7. 
Have extrahepatic metastasis. 
8. 
Have portal or hepatic vein tumor invasion/thrombosis. 
9. 
Have body temperature >101ºF (38.3ºC) immediately prior to study treatment. 
10. Baseline laboratories (repeat lab tests are permitted to evaluate eligibility during 
the Screening Period. Lab results must be within protocol range prior to study 
treatment.) 
• Absolute neutrophil count < 1500/mm3 


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• Platelet count < 75,000/mm3 
• Hgb < 10.0 g/dL (unless the hemoglobin value has been stable, the subject 
is cardiovascularly stable, asymptomatic and judged able to withstand the 
RFA procedure) 
Note: If clinically indicated, subjects may receive platelets or packed RBC 
transfusions and be re-evaluated after condition is treated. 
11. Baseline Chemistry 
• Serum creatinine ≥ 2.5 mg/dL or calculated creatinine clearance (CrCl) 
≤25.0 mL/min. 
• Serum bilirubin > 3.0 mg/dL. 
• Serum albumin < 2.8 g/dL.   
12. Have any known allergic reactions to any of the drugs or liposomal components 
or intravenous imaging agents that prohibit the ability to complete the imaging 
requirements. 
13. Are pregnant or breast-feeding. In women of childbearing potential, a negative 
serum pregnancy test is required prior to study treatment.   
14. Women of childbearing potential and men who are not practicing an acceptable 
form of birth control (i.e. diaphragm, cervical cap, condom, surgical sterility or 
birth control pills. Women whose partner has or men who have undergone a 
vasectomy must use a second form of birth control).   
15. Have INR > 1.5 times the institution’s upper normal limit (UNL), except in 
subjects who are therapeutically anticoagulated for medical conditions unrelated 
to HCC such as atrial fibrillation. Subjects may be re-screened after condition is 
treated or anticoagulant is withheld.  
16. Have contraindications to receiving doxorubicin HCl. 
17. Are being treated with other investigational agents. 
18. Use of an investigational drug outside this study within 30 days or 5 half-lives, 
whichever is longer, preceding the first dose of study medication. 
19. Have other concurrent malignancy (subjects with treated squamous cell 
carcinoma of the skin or basal cell carcinoma of the skin may be included), 
evidence of extrahepatic cancer from their primary malignancy, or ongoing, 
medically significant active infection. 
20. HIV positive. 
21. NYHA class III or IV functional classification for heart failure.  
22. Evidence of hemachromatosis. 
Trial Drug, Dose 
and 
Administration 
 
Oral Premedication: As part of a blinded premedication regimen, subjects will be  
assigned to take 20 mg of oral dexamethasone (ThermoDox arm) or matching 
dummy capsule (Control arm) 24 hours (+/- 2 hours) prior to the scheduled RFA 
procedure.  
 
Intravenous Premedication: IV premedication regimen of steroids H1 and H2 
antihistamines (ThermoDox arm) according to local formularies or dummy IV 
premedication of Sodium Chloride 0.9% or D5W (Control arm) will be administered 
in a blinded fashion. IV medications should be given within 30 minutes (+15 min 
window) prior to infusion of study drug. 
 
 


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Study Drug Infusion:  A 50 mg/m2 ThermoDox infusion (ThermoDox arm) or 
dummy infusion of Dextrose 5% Solution or Sodium Chloride 0.9% (Control arm) 
will be administered IV over 30 minutes. 
 
The Sponsor will provide blinded masking materials to maintain the blind and 
unblinded site representative(s) (i.e. pharmacist) will prepare the materials to cover 
IV bags and tubing. 
 
Radiofrequency Ablation: Only FDA approved RFA devices are permitted for this 
trial. RFA requiring a standardized dwell time ≥ 45 minutes will be initiated 15 
minutes (+5 min.) after the start of the study drug infusion with an estimated overall 
procedure time of less than 3 hours. A standardized Radiofrequency Ablation sRFA 
treatment for this protocol is defined as the dwell time of ≥ 45 minutes measured 
from the first activation of the RFA probe to produce coagulative necrosis of target 
tissue through removal of the RFA probe after the final ablation cycle or 
deployment.. This includes the multiple ablation cycles and repositioning time 
between cycles for an individual patient. An ablation cycle for this protocol is 
defined as the single activation of the probe or electrode in order to achieve a local 
coagulation necrosis in target tissue. The cycle may be completed by achieving a 
target temperature in the tissue or a target impedance. 
 
The goal is to ablate the tumor as well as a 360º 1.0 cm tumor-free margin 
surrounding the tumor. Tumor uptake of ThermoDox is enhanced with a 
standardized treatment dwell time of at least 45 minutes (30 minutes with a 
switchbox). The literature recommends tumors ≥ 3 cm should require at least four 
ablation spheres (if using simple needle electrode) or at least four deployments (if 
using multiple array LeVeen needle electrode). More ablations may be performed at 
the discretion of the operator, however the RFA probe dwell time must reach 45 
minutes. 
 
Pringle maneuver or balloon occlusions are prohibited. 
Sample Size: 
The study is designed to detect with 80% power a hazard ratio for OS of 0.67 (33% 
risk reduction) in the ThermoDox (TR) arm compared with the control (PR) arm 
with an overall 1-sided type 1 error of 0.025. An OS hazard ratio of 0.63 was 
observed in an earlier trial among HCC patients with a solitary 3-7 cm lesion 
treated with ≥ 45 minutes of RFA treatment dwell time. A 3%/year loss to 
survival follow-up rate has been assumed and using a 1:1 treatment allocation 
(TR:PR) of 550 subjects, a target of 197 events (deaths) will be required for the 
primary analysis. Two interim analyses, both for efficacy and futility, are planned for 
the study. The first is planned after 60% of the target events is reached (118 deaths) 
and the second after 80% of the events has been reached (158 deaths). 
Criteria for 
Evaluation 
Efficacy Evaluations: 
Overall survival is defined as the time from the date of randomization to the date of 
death.  If death is not observed during the study, survival time will be 
censored at the date of last study follow-up, or the cut-off date,  whichever is 
earlier. 
 


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Progression-free survival is defined as the time from the date of randomization until 
the date of Investigator-assessed radiological disease progression or death due to any 
cause. Subjects who are alive with no disease progression as of the analysis cut-off 
date will be censored at the date of the last tumor assessment.   
 
Safety 
All subjects will have adverse event (AE) assessments as well as other safety 
assessments 
such 
as 
physical 
examinations, 
vital 
signs, 
ECGs, 
echocardiograms/MUGA scans, hematology, clinical chemistry, and urinalysis 
beginning at time of signing of informed consent and continuing through Day 28 
following study drug administration.   
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the 
following additional safety assessments will be done: 
 
• 
Physical examination, assessment of vital signs, ECGs, CBC with differential, 
serum chemistry, PT/INR and urinalysis at Month 5, Month 9, and Month 13 
(+/- 2 weeks) or at disease progression, whichever occurs first. 
• 
LVEF monitoring at Month 13 or at disease progression, whichever occurs first 
• 
Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 
25 (+/- 2 weeks) or at disease progression, whichever occurs first. 
  
Subjects with elevated bilirubin levels > 2.0 mg/dL and ≤ 3.0 mg/dL at baseline will 
return to the clinic on Day 7 for additional safety assessments.    
 
Adverse event (AE) assessments will begin at time of signing informed consent 
through Day 28 visit after the last study treatment. AEs which are assessed as 
possibly, probably, or definitely related to study treatment will be recorded at any 
point during the trial and must be followed until resolution or until the patient is 
clinically stable.  
 
Data Monitoring 
Committee 
An independent Data Monitoring Committee (DMC) will be established by the 
Sponsor to review accumulating safety data at regular intervals throughout the study 
and to monitor trial data integrity. The DMC is responsible for unblinded monitoring 
of subjects with elevated (> 2.0 mg/dL and < 3.0 mg/dL) serum bilirubin levels and 
will advise if any dose or protocol modification is needed to mitigate risk to such 
patients. The DMC will also evaluate the results of preplanned interim efficacy and 
futility analyses for OS. The DMC’s specific duties as well as statistical monitoring 
guidelines and procedures will be fully described in the DMC Charter. 
Statistical 
Methods 
 
OS in the Intent to Treat population will be compared between the two treatment 
groups using the stratified log-rank test. The estimate of the hazard ratio and 
corresponding 95% CI will be provided using a Cox proportional hazards (CPH) 
model including treatment and the stratification factors (maximum lesion diameter 
[3-5 cm versus > 5-7 cm] and RFA route [laparoscopic, open surgical, 
percutaneous[) in the model. The survival curves will be estimated using Kaplan-
Meier estimates. PFS will be analyzed using the same methodology. 


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Sponsor Contact 
 
Celsion Corporation 
997 Lenox Drive, Suite 100 
Lawrenceville, NJ 08648,  USA 
Tel: XXXXXXXXXX 0 Fax: XXXXXXXXXX 
 
 
 


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2. 
LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
AASLD 
American Association for the Study of Liver Disease 
ACS 
Almac Clinical Services 
AE 
Adverse Event 
AFP 
Alpha-Fetoprotein 
ALT 
Alanine Aminotransferase 
ANC 
Absolute Neutrophil Count 
ANOVA 
Analysis of Variance 
AST 
Aspartate Aminotransferase 
BP 
Blood Pressure 
BUN 
Blood Urea Nitrogen 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CIN 
Contrast-Induced Nephropathy 
CR 
Complete Response 
CrCl 
Creatinine Clearance 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CT 
Computerized Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CYP3A4 
Cytochrome P450 3A4 
D5W 
5% Dextrose Solution 
DHR 
Distant Hepatic Recurrence 
DLT 
Dose-limiting toxicity 
DMC 
Data Monitoring Committee 
DSPE-MPEG 
N-(methoxypolyethyleneglycolcarbomyl) distearoylphosphatidyl-
ethanolamine 
EC 
Ethics Committee 
EF 
Ejection Fraction 
ECG 
Electrocardiogram 
EHR 
Extrahepatic Recurrence 
FDA 
Food and Drug Administration 
GCPs 
Good Clinical Practices 
GCSF 
Granulocyte Colony-Stimulating Factor 
GGT 
Gamma Glutamyl Transpeptidase 
GI 
Gastrointestinal 
HCC 
Hepatocellular Carcinoma 
Hct 
Hematocrit 


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Abbreviation 
Definition 
Hgb 
Hemoglobin 
HIV 
Human Immunodeficiency Virus 
HT 
Hyperthermia 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonization 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug 
INR 
International Normalized Ratio 
IR 
Incomplete Response 
IRB 
Institutional Review Board 
IRC 
Independent Radiology Charter 
IRRC 
Independent Radiology Review Committee 
IV 
Intravenous 
LDH 
Lactate Dehydrogenase 
LR 
Local Recurrence 
LTLD 
Lyso-Thermosensitive Liposomal Doxorubicin; ThermoDox® 
LTSL 
Lyso-Thermosensitive Liposome 
LTFS 
Liver Transplant-Free Survival 
LVEF 
Left Ventricular Ejection Fraction 
MLC 
Metastatic Liver Cancer 
MR 
Minor Response 
MSPC 
1-steroyl-2-hydroxy-SN-glycero-3-phosphoaholine 
MTD 
Maximum Tolerated Dose 
MUGA 
Multiple gated acquisition 
NCR 
No Carbon Required 
NYHA 
New York Heart Association 
OS 
Overall Survival 
PD 
Pharmacodynamics 
PFS 
Progression-Free Survival 
PEI 
Percutaneous Ethanol Injection 
PO 
Orally 
PR 
Partial Response 
PRO 
Patient-Reported Outcomes 
PT/PTT 
Prothrombin Time/Partial Thromboplastin Time 
RBC 
Red Blood Cells 
RCW 
Recurrent Chest Wall 
RF 
Radiofrequency 
RFA 
Radiofrequency Ablation 
SAE 
Serious Adverse Event 


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Abbreviation 
Definition 
SC 
Steering Committee 
SD 
Stable Disease 
sRFA 
Standardized Radiofrequency Ablation with treatment dwell time ≥45 
min. 
CFDA 
China Food and Drug Administration  
SGOT 
Serum glutamic-oxaloacetic transaminase 
SGPT 
Serum glutamate pyruvate transaminase 
TACE 
Transarterial Chemoembolization 
TTLR 
Time to Local Recurrence 
TTP 
Time to Progression 
UA 
Urinalysis 
UNL 
Upper Normal Limit 
WBC 
White Blood Cells  
 


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3. 
INTRODUCTION  
3.1 Overview 
Hepatocellular carcinoma is the sixth most common neoplasm worldwide, but its very poor 
prognosis makes it the third leading cause of cancer-related mortality, responsible for about 
600,000 deaths annually (Parkin, et al. 2005). In the US, 18,000 new cases of HCC are 
diagnosed each year and the incidence is steadily increasing, almost doubling since 1998. 
HCC is commonly diagnosed in patients with longstanding hepatic disease and cirrhosis 
(primarily due to hepatitis C in US and Europe and to hepatitis B in Asia). Mortality and 
hospitalization due to HCC, as well as hospital-related costs (inflation adjusted), increased 
approximately two-fold from 1988 to 2000 (Kim et al. 2005, Thomas and Abbruzzese 2005). 
The incidence of extrahepatic metastases in patients with HCC is generally around 15%, 
which includes such metastases both at the initial diagnosis of HCC or during follow-up 
regardless of treatment (Uka, et al. 2007; Yang, et al. 2007). 
 
The Barcelona Clinic Liver Cancer (BCLC) staging and treatment system is widely accepted 
in clinical practice and is also being used in many clinical trials of new drugs to treat HCC. 
Therefore, it has become the de facto staging system that guides HCC treatment. The BCLC 
system recognizes three treatments as curative for patients with up to 3 HCC lesions, each < 
3.0 cm, who have WHO performance status 0 and no more than Child-Pugh class B liver 
impairment. The three curative therapies are surgical resection, liver transplantation, and 
radiofrequency ablation (RFA). Patients with HCC lesions ≥ 3 cm are considered incurable. 
Transarterial chemoembolization (TACE) is recommended as a palliative treatment for 
patients with WHO performance status 0 and sorafenib is recommended as a palliative 
treatment for patients with WHO performance status 1-2 (Bruix and Sherman, 2011).  
 
Surgical resection is the mainstay of curative treatment. However, no more than 30% of HCC 
patients are considered suitable for surgical treatment because of tumor size, multifocal 
tumors, vascular invasion, presence of extrahepatic metastases, and/or extensive liver 
impairment. Liver transplantation is an alternative curative treatment, but its application is 
limited by a severe shortage of liver graft donors (Llovet, et al. 2008). Thermal ablation 
modalities such as radiofrequency ablation (RFA), microwave ablation, and high-intensity 
focused ultrasound have emerged as important treatment options for such patients in recent 
years.  
 
To sum up, the worldwide HCC population is large and growing. The vast majority, 
including all those with tumors ≥ 3 cm, are incurable. These patients have an unmet need for 
more effective therapies. 
 
3.2 Radiofrequency Ablation (RFA) 
RFA can be applied repeatedly to the same patient to treat multiple tumors at time of 
diagnosis or upon tumor recurrence. There are presently three RFA systems approved by the 
FDA and currently marketed in the U.S for ablation of soft tissue: Angiodynamics, Boston 
Scientific, and Covidien.  Please refer to Appendix IV for equipment specifications. 
 


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In general, RFA systems are comprised of a generator and a family of application-specific 
electrodes containing deployable arrays, saline infusion, or water-cooled needles, all of 
which enable predictable volumes of tissue to be ablated. Ablation is usually guided by 
computerized tomography (CT), magnetic resonance (MR), or ultrasound. Temperature, 
impedance (the ratio of voltage to electric current), and time may be monitored during the 
treatment to allow for accurate control of the energy delivered to the lesion and thus the 
amount of tissue subjected to thermal injury. Both complete and partial responses have been 
observed utilizing RFA and results have been comparable to those obtained with cryotherapy 
(Siperstein, et al. 1997; Rossi, et al. 1995; Buscarini, et al. 1995). A recent study in China 
(Chen, et al. 2006) compared RFA and surgery and found no difference in mortality between 
the two treatments. This study suggests that there are clinicians who consider RFA to be a 
viable alternative to surgery. Randomized trials have found that RFA has overall survival 
similar to surgical resection for solitary tumors < 5 cm (Chen, et al. 2006) and better overall 
survival than percutaneous ethanol injection (PEI) for 1-3 tumors < 3 cm (Lin, et al. 2005; 
Shiina, et al. 2005) and for 1-3 tumors < 4 cm (Lin, et al. 2004). The better performance of 
RFA versus PEI in these HCC studies may relate to RFA’s greater certainty of achieving a 
0.5 to 1.0 cm tumor-free margin around the tumor boundary.  
 
Approximately 2% of patients undergoing RFA of liver tumors experience major 
complications due to the procedure including intraperitoneal hemorrhage, intrahepatic 
abscesses, gastrointestinal wall perforations, and hemothorax (Berber, et al. 2005a and 
2005b). More common minor complications, typically reported in 5% or less of patients, can 
include altered liver function tests, self-limited bleeding, effusions, pain, fever, infection, and 
skin burn (Berber, et al. 2007).  
 
RFA has been used safely in tumors up to 7 cm (Chen, et al. 2004; Curley, et al. 2004; Dodd, 
et al. 2001; Tateishi, et al. 2005).  In the United States, palliative treatments such as 
transcatheter arterial chemoembolization (TACE) and sorafenib are the standard treatment 
options for HCC tumors > 5 cm. However, in this study the combination of RFA and 
ThermoDox is being investigated as a curative treatment for patients with tumors > 5 cm to < 
7 cm rather than for their palliation.  
 
For HCC tumors > 3 cm, overlapping ablations are required, and this overlapping can miss 
some micrometastases (Chen, et al. 2004; Curley, 2001; Dodd, et al. 2001; Chen, et al. 2006). 
If the efficacy of RFA for HCC tumors ≥ 3.0 cm could be increased, as by an adjuvant, it 
would be a formidable curative modality. 
 
In this study, RFA treatments will be administered according to the RFA Treatment 
Procedure and device instructions (Appendix IV). Investigators at each site that meet the 
experience qualifications to perform RFA in this study will complete formal training with an 
accompanying RFA training manual developed by the Sponsor. All subjects will undergo an 
RFA treatment dwell time lasting ≥ 45 minutes.   
 


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3.3  ThermoDox 
Lyso-Thermosensitive Liposomal Doxorubicin (ThermoDox) is designed for use with RFA 
and consists of the heat-enhanced cytotoxic anthracycline antibiotic doxorubicin within a 
heat-activated liposome. At normal body temperatures (i.e., 37°C), the product is designed to 
retain doxorubicin within the liposome as it travels around the body. However, with mild 
heating, (i.e., > 40.0°C), the liposome component of ThermoDox very quickly releases its 
active doxorubicin ingredient, which rapidly diffuses into the local tissue.  
 
ThermoDox is administered intravenously and, because it is a liposome, exhibits prolonged 
systemic circulation relative to free (non-liposomal) doxorubicin, with a small portion being 
taken up by mononuclear phagocytic system (MPS) cells in the liver. During 
RFA/ThermoDox therapy, cytocidal heat is directed to a tumor. When heat-sensitive 
liposomes encounter a temperature of 40.0°C or above, their doxorubicin is released into the 
heated area. The released doxorubicin remains stable up to 90°C (Wood, et al. 2012). So, the 
antitumor activity of ThermoDox/doxorubicin requires mild (≥ 40.0°C) hyperthermia and 
tissue perfusion to deliver a high concentration of doxorubicin to the tumor margins. 
 
The systemic delivery of ThermoDox in conjunction with local hyperthermia creates a high 
concentration of doxorubicin in the immediate region of the tumor, through the release of 
doxorubicin from ThermoDox liposomes at the site. The temperature isotherms produced in 
this boundary region during RFA should be adequate to activate the release of encapsulated 
doxorubicin deposited locally around the ablation zone and in the tumor vasculature at the 
time of heating. This process extends the region of tissue that can be treated beyond that 
achievable by use of RFA alone.  
 
Gasselhuber, et al. (2012) published a computational model of doxorubicin concentration in 
liver tumor tissue following combination therapy with ThermoDox and mild hyperthermia, 
(target temperature 43°C). Their model found a direct correlation between duration of 
hyperthermia and doxorubicin tumor tissue concentration. This finding suggests the 
hypothesis that, when used with ThermoDox, length of heating time can be used to ensure 
delivery of a doxorubicin dose needed to provide a therapeutic effect in tumor tissue. 
Although this study utilized mild hyperthermia, the principle of heat time translating into 
doxorubicin dose is readily applicable to RFA procedures. 
 
A 2013 study in healthy pigs receiving intravenous ThermoDox and RFA of the liver is 
consistent with the hypothesis that doxorubicin target tissue concentration directly covaries 
with duration of hyperthermia (Swenson, 2014). Furthermore, fluorescence imaging found 
high doxorubicin concentrations in the margin of the ablation zone and in areas where 
ablations overlapped, supporting the hypothesis that ThermoDox addresses any microscopic 
tumors left behind in the clefts of overlapping ablations.  
 
Haemmerich and Rossmann (2013) conducted a ThermoDox + RFA modeling study. They 
found that the amount of bioavailable doxorubicin in the tumor margin increases as the actual 
heating time increases. They also found that beginning RFA 15 minutes after starting a 30-
minute ThermoDox infusion maximizes the amount of bioavailable doxorubicin in the tumor 
margin compared to beginning RFA later.  


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In Celsion’s initial phase III trial, the HEAT Study (Protocol 104-06-301), the criterion for 
RFA adequacy was that it ablate each target lesion plus a 360° 1-cm tumor margin; there was 
no attempt to manage RFA so as to also increase doxorubicin tumor tissue concentration. The 
results of the HEAT Study became available in 2013. The trial achieved the expected level of 
safety. The overall safety profile was consistent with literature reports for liposomal 
doxorubicin and free doxorubicin commercial labels. Other than reversible neutropenia and 
leukopenia, both treatment-related adverse events ≥ grade 3 and serious adverse events were 
rare, affecting < 5% of patients in either arm. However, the primary endpoint of progression 
free survival (PFS) was not met. Patients are still being followed for overall survival (OS). 
 
Post hoc analysis of the PFS and OS data from the HEAT Study suggests that ThermoDox 
efficacy for the treatment of single lesions is greatly improved when RFA dwell time is ≥ 45 
minutes. An sRFA treatment for this protocol is defined as the dwell time of ≥ 45 minutes 
measured from the first activation of the RFA probe to produce coagulative necrosis of target 
tissue through removal of the RFA probe after the final ablation cycle or deployment. This 
includes the multiple ablation cycles and repositioning time between cycles for an individual 
patient. Dwell time is relevant for ThermoDox activity because the target tissue and 
surrounding tissue remain at ≥ 40.0°C, even between ablation cycles. This minimum 
effective dose (MED) of RFA dwell time is achieved by administering 4 ablation cycles. In 
this trial, all patients will receive the RFA MED of ≥ 45 minutes dwell time; in addition, half 
will be randomized to the ThermoDox MTD of 50 mg/m2 and half will be randomized to a 
dummy infusion of D5W or saline. Randomization and analysis will be stratified by lesion 
diameter (3-5 cm versus > 5-7 cm) and RFA route (laparoscopic, open surgical, 
percutaneous)  Lesion diameter was found to be a statistically significant prognostic factor in 
the prior study. Although nearly all subjects in the prior trial (90.7%; 636/701) received 
percutaneous RFA, this study will also stratify by RFA route for the sake of consistency with 
the earlier trial’s design. Unlike the prior trial, Child Pugh B patients will not be enrolled. 
They are much more likely than Child Pugh A patients to die from their underlying liver 
disease, confounding the effect of anticancer treatment (Llovet, et al. 2008). In the HEAT 
Study, deaths prior to HCC progression occurred at a rate almost five times higher in Child 
Pugh B patients (19.5%; 8/41) than in Child Pugh A patients (4.1%; 27/660).  
 
 
4. 
OBJECTIVES  
4.1 Primary Objective 
The primary objective is to compare overall survival (OS) between patients receiving RFA 
plus ThermoDox versus RFA alone, using a standardized Radiofrequency Ablation (sRFA) 
treatment dwell time ≥ 45 minutes. 
 
4.1.1 
Measurement of the Primary Objective 
  
Overall survival will be measured by time from randomization to death from any cause or the 
end of the study. OS will be compared between the treatment arms. 


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4.2 Secondary Objectives 
The secondary objectives are to compare progression-free survival (PFS) and safety between 
patients receiving sRFA plus ThermoDox versus sRFA alone, using a standardized RFA 
treatment dwell time ≥ 45 minutes. 
 
4.2.1 
Measurement of Secondary Objectives 
PFS will be measured from the date of randomization to the first date on which one of the 
following occurs, as determined by CT or MRI scan:  
• Death of any cause  
• Treatment failure (inability to achieve CR after two RFA ± ThermoDox treatment 
sessions)  
• Progression due to local tumor recurrence after initial CR  
• Progression due to distant intrahepatic tumor recurrence  
• Progression due to extrahepatic tumor recurrence  
 
 Adverse events (AEs) assessment will begin at time of signing informed consent through 
Day 28 visit following the last study treatment. Adverse events which are assessed as 
possibly, probably, or definitely related to study treatment will be recorded at any point 
during the trial and must be followed until resolution or the patient is clinically stable. 
 
Other 
safety 
data 
including 
physical 
examinations, 
vital 
signs, 
ECGs, 
echocardiograms/MUGA scans, hematology, clinical chemistry, and urinalysis will be 
assessed through Day 28 following study treatment..  
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the following 
additional safety assessments will be done: 
 
• Physical examination, assessment of vital signs, ECGs, CBC with differential, serum 
chemistry, PT/INR and urinalysis at Month 5, Month 9, and Month 13 (+/- 2 weeks) or 
at disease progression, whichever occurs first. 
• LVEF monitoring at Month 13 or at disease progression, whichever occurs first 
• Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 25 (+/- 2 
weeks) or at disease progression, whichever occurs first. 
 
Subjects with elevated bilirubin levels > 2.0 mg/dL and ≤ 3.0 mg/dL at baseline will return to 
the clinic on Day 7 for additional safety assessments. 
 
 


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5. 
STUDY PLAN  
5.1 Design Overview 
This is a randomized, double blind, dummy controlled multicenter trial to evaluate the safety 
and efficacy of ThermoDox plus sRFA compared to sRFA alone using standardized 
treatment dwell time for solitary HCC lesions ≥ 3.0 cm to ≤ 7.0 cm. An sRFA treatment for 
this protocol is defined as the dwell time of ≥ 45 minutes measured from the first activation 
of the RFA probe to produce coagulative necrosis of target tissue through removal of the 
RFA probe after the final ablation cycle or deployment. This includes the multiple ablation 
cycles and repositioning time between cycles for an individual patient. 
 
Eligible HCC patients will have a solitary lesion not amenable to curative resection 
consistent with clinical diagnosis by AASLD classification guidelines and will be candidates 
for RFA. Subjects will be randomly assigned to receive sRFA plus 50 mg/m2 of ThermoDox 
or sRFA plus a dummy infusion using a standardized RFA dwell time ≥ 45 minutes. 
Randomization and analysis will be stratified by maximum lesion diameter (≥ 3.0 to 5.0 cm 
versus > 5.0 to 7.0 cm) and RFA route (laparoscopic, open surgical, percutaneous). 
 
Screening Period  
Subjects will be evaluated up to 21 days prior to the RFA procedure date to establish 
eligibility for the study treatment. Subjects must meet all of the study inclusion/exclusion 
criteria prior to randomization to a treatment arm.  
 
Treatment Period 
Subjects will be randomly assigned to either sRFA plus ThermoDox or sRFA plus dummy 
infusion using a central web-based randomization system. The RFA procedure day will be 
Day 0 and subjects will return to the clinic Day 14 and Day 28 (+/- 3 days).  Subjects with a 
complete ablation by imaging will continue in the follow up period described below. 
 
As part of a blinded premedication regimen, subjects will be assigned to take 20 mg of oral 
dexamethasone (ThermoDox arm) or matching dummy capsule (control arm) 24 hours (+/- 2 
hours) prior to the scheduled sRFA procedure.  
 
The IV premedication should be administered within 30 minutes (+15 min.) prior to the start 
of the ThermoDox infusion. The following may serve as a guide: 
• Dexamethasone 20 mg IV or dummy infusion of Sodium Chloride 0.9% or 5% 
Dextrose (D5W) 
• Diphenhydramine 50 mg IV (chlorpheniramine 10 mg IV is permitted) or dummy 
infusion of Sodium Chloride 0.9% or 5% Dextrose (D5W)  
• Ranitidine 50 mg IV or famotidine 20 mg IV or dummy infusion of Sodium Chloride 
0.9% or 5% Dextrose (D5W) 
 
Study drug will be administered IV over 30 minutes in a blinded fashion. 
• Treatment arm subjects will receive a 50 mg/m2 ThermoDox infusion. 


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• Control arm subjects will receive a dummy infusion of D5W (250 cc of 5% Dextrose 
solution) or Saline (250 cc of 0.9% Sodium Chloride).  
 
The Sponsor will provide blinded masking materials to maintain the blind and unblinded site 
representative(s) (i.e., pharmacist) will prepare the materials to cover IV bags and tubing. 
 
Only US FDA approved RFA devices are permitted for this trial. RFA requiring a 
standardized dwell time ≥ 45 minutes will be initiated at minute 15 (+5 minutes) following 
the start of the study drug infusion with an estimated overall procedure time of less than 3 
hours. An sRFA treatment for this protocol is defined as the dwell time of ≥ 45 minutes 
measured from the first activation of the RFA probe to produce coagulative necrosis of target 
tissue through removal of the RFA probe after the final ablation cycle or deployment. This 
includes the multiple ablation cycles and repositioning time between cycles for an individual 
patient. An ablation cycle for this protocol is defined as the single activation of the probe or 
electrode in order to achieve a local coagulation necrosis in target tissue. The cycle may be 
completed by achieving a target temperature in the tissue or a target impedance. 
 
The goal is to reach a > 45 minute dwell time which can be achieved by employing at least 
four ablation cycles or deployments in order to ablate the tumor as well as a 360º 1.0 cm 
tumor-free margin surrounding the tumor. Tumor uptake of ThermoDox is enhanced with 
standardized treatment times of at least 45 minutes (30 minutes with a switchbox). The RFA 
literature recommends a minimum of 4 ablation cycles to ablate tumors of ≥ 3.0 cm together 
with a 360° 1.0-cm margin (Chen, et al. 2004). 
 
According to literature, tumors ≥ 3 cm should require at least four ablation spheres (if using 
simple needle electrode) or at least four deployments (if using multiple array LeVeen needle 
electrode). More or fewer ablations may be performed at the discretion of the operator, 
however the RFA probe dwell time must reach 45 minutes. 
 
The sRFA procedure day will be recorded as Day 0 and subjects will return to the clinic Day 
14 and Day 28 (+/- 3 days). Subjects with baseline bilirubin levels > 2.0 mg/dL and ≤ 3.0 
mg/dL will return to the clinic on Day 7 for additional safety assessments. Subjects with a 
complete ablation by imaging will continue in the follow-Up period described below.   
 
Safety data including physical examinations, vital signs, ECGs, echocardiograms/MUGA 
scans, hematology, clinical chemistry, and urinalysis will be assessed through Day 28 
following study treatment. Adverse events (AEs) will be reported and exclusion concomitant 
medications are restricted through Day 28 following the last study treatment. Adverse events 
which are assessed as possibly, probably, or definitely related to study treatment will be 
recorded at any point during the trial and must be followed until resolution or the patient is 
clinically stable.  
 
Subjects with a complete ablation by imaging at Day 28 will continue in the follow-up 
period and be followed for PFS and OS.   
 


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A subject who has an incomplete ablation is eligible for 1 retreatment procedure within 21 
days after the radiological imaging exam showing residual disease at Day 28. Subjects will 
be retreated only once with the same RFA equipment and treatment assigned at 
randomization. Baseline safety evaluations must meet the eligibility parameters prior to a 
retreatment. Repeat screening data will be recorded into the Case Report Form. The second 
ablation must occur no later than 21 days after the first post-ablation scan assessment at Day 
28. Subjects with a complete ablation after retreatment will be followed both for PFS and for 
OS. If after 2 ablations the subject has local, distant intrahepatic, or extrahepatic HCC, then 
the subject will be considered a treatment failure and will have met the PFS endpoint. The 
subject will be followed for OS every 3 months.   
 
Among subjects who are not treatment failures, five repeat treatments are permitted to treat a 
recurrent lesion or to treat newly-identified local or distant intrahepatic lesions at the 
Investigator’s discretion after the PFS endpoint is reported and with agreement from the 
Sponsor. The subject must be eligible for retreatment consistent with the safety eligibility 
criteria and will be retreated with the same randomized treatment. 
 
Subjects who develop extrahepatic lesions will have met the PFS endpoint and are no longer 
eligible for further protocol treatment; they will be followed for OS. 
 
Follow-Up Period 
 
Following study treatment subjects will undergo CT or MRI imaging scans (chest, abdomen 
and pelvis)  at months 1, 5, 9, 13, 17, 21, 25, then every 6 months (+/- 2 weeks) until 
radiological progression is seen. The same imaging equipment, technique, and measurement 
of assessment should be used to characterize disease at baseline and during follow up for an 
individual patient. Investigator determined radiological progression must be observed and 
recorded prior to beginning alternate treatments for HCC. Post-progression treatments will 
be reported and the subject will continue to be followed for OS. 
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the following 
additional safety assessments will be done: 
 
• Physical examination, assessment of vital signs, ECGs, CBC with differential, serum 
chemistry, PT/INR and urinalysis at Month 5, Month 9, and Month 13 (+/- 2 weeks) or 
at disease progression, whichever occurs first. 
• LVEF monitoring at Month 13 or at disease progression, whichever occurs first 
• Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 25 (+/- 2 
weeks) or at disease progression, whichever occurs first. 
 
The site will contact all subjects every 3 months after radiological progression to document 
vital status until the subject expires or withdraws consent from the study. These follow-up 
contacts across all clinical sites may be coordinated using the same 3-month interval. 
 


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5.2 Trial Termination 
For reasonable cause, either the Investigator or the Sponsor may terminate this study 
prematurely. Written notification of the termination is required. Conditions that may warrant 
termination include, but are not limited to: 
• The discovery of an unexpected, significant, or unacceptable risk to the subjects 
enrolled in the study. 
• Failure of the Investigator to enter subjects at an acceptable rate. 
• Insufficient adherence to protocol requirements (non-compliance). 
• Lack of evaluable and/or complete data. 
• Decision to modify the developmental plan of the drug. 
• A decision on the part of the Sponsor to suspend or discontinue development of 
the drug. 
• Regulatory authority decision. 
 
 
6. 
STUDY POPULATION 
6.1 Source and Number of Subjects 
Approximately 550 subjects will be randomized at approximately 100 centers worldwide. 
  
6.2 Subject Selection Criteria 
6.2.1 
Overview 
This clinical trial can fulfill its objectives only if appropriate subjects are enrolled. The 
following eligibility criteria are designed to select subjects for whom study participation is 
considered appropriate.  All relevant medical and non-medical conditions should be taken 
into consideration when deciding whether this protocol is suitable for a particular subject. 
Eligibility criteria may not be waived by the Investigator and are subject to review in the case 
of a GCP or a regulatory authority audit. Any questions regarding a subject’s eligibility 
should be discussed with the Celsion medical monitor (see List of Study Representatives at 
the beginning of the protocol) prior to study treatment.  
 
6.2.2 
Inclusion Criteria 
Subjects must fulfill all of the following inclusion criteria to be eligible to participate in the 
study.   
 
Subjects may be randomized without a biopsy if they meet American Association for 
the Study of Liver Disease (AASLD) criteria for the diagnosis of HCC (see Appendix 
VIII).  Subjects not meeting AASLD criteria for HCC will need a biopsy for confirming 
HCC prior to randomization.  
 
 


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1.  Male or female ≥ 18 years of age 
2.  Diagnosed with a single HCC lesion ≥ 3.0 cm but ≤ 7.0 cm in maximum diameter 
based on diagnosis at screening.  
• 
Subjects meeting the AASLD criteria may be randomized without a biopsy, but 
will undergo a biopsy during the RFA procedure unless contraindicated or 
unattainable. 
• 
Subjects not meeting the AASLD criteria for HCC will need a biopsy to confirm 
HCC prior to randomization. 
3. Be an appropriate candidate for receiving RFA as a medically indicated treatment as 
evaluated by the following factors: 
• 
The position and accessibility of the target lesion allows for the safe administration of 
multiple ablation cycles or deployments to achieve a probe dwell time of ≥ 45 minutes.  
•  
• Not a candidate for surgical resection according to the local guidelines for 
resection and in the Investigator’s judgment.  
4.  Child-Pugh Class A without either current encephalopathy or ascites 
5.  Left ventricular ejection fraction (LVEF)  ≥ 50% 
6.  ECOG performance status 0 
7. Willing to sign an informed consent form, indicating awareness of the investigational 
nature of this study that is in keeping with the policies of the institution. 
 
6.2.3 
Exclusion Criteria 
Subjects meeting any of the following criteria will be excluded from the study:  
1. Is scheduled for liver transplantation.   
2. Expected ablation volume > 30% of total liver volume or removal of 3 hepatic 
segments 
3. More than 1 lesion identified during baseline.  
4. Have previously received therapeutic treatment for HCC outside the study protocol or 
is expected to receive concomitant HCC treatment prior to PFS event. 
5. Have serious medical illnesses including, but not limited to, congestive heart failure, 
myocardial infarction or cerebral vascular accident within the last six months, or life 
threatening cardiac arrhythmias. 
6. Have previously received any anthracycline outside the protocol.  
7. Have extrahepatic metastasis. 
8. Have portal or hepatic vein tumor invasion/thrombosis. 
9. Have body temperature > 101ºF (38.3ºC) immediately prior to study treatment.  
10. Baseline laboratories (repeat lab tests are permitted to evaluate eligibility during the 
Screening Period. Lab results must be within protocol range prior to study treatment.) 
• 
Absolute neutrophil count < 1500/mm3 
• 
Platelet count < 75,000/mm3 
• 
Hgb < 10.0 g/dL (unless the hemoglobin value has been stable, the subject is 
cardiovascularly stable, asymptomatic and judged able to withstand the RFA 
procedure) 
Note: If clinically indicated, subjects may receive platelets or packed RBC 
transfusions and be re-evaluated after condition is treated. 


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11. Baseline Chemistry 
• 
Serum creatinine ≥ 2.5 mg/dL or calculated creatinine clearance (CrCl) ≤ 25.0 
mL/min. 
• 
Serum bilirubin > 3.0 mg/dL. 
• 
Serum albumin < 2.8 g/dL.   
12. Have any known allergic reactions to any of the drugs or liposomal components or 
intravenous imaging agents that prohibit the ability to complete the imaging 
requirements. 
13. Are pregnant or breast-feeding. In women of childbearing potential, a negative serum 
pregnancy test is required prior to study treatment.   
14. Women of childbearing potential and men who are not practicing an acceptable form 
of birth control (i.e. diaphragm, cervical cap, condom, surgical sterility or birth 
control pills. Women whose partner has or men who have undergone a vasectomy 
must use a second form of birth control).   
15. Have INR > 1.5 times the institution’s upper normal limit (UNL), except in subjects 
who are therapeutically anticoagulated for medical conditions unrelated to HCC such 
as atrial fibrillation. Subjects may be re-screened after condition is treated or 
anticoagulant is withheld.  
16. Have contraindications to receiving doxorubicin HCl. 
17. Are being treated with other investigational agents. 
18. Use of an investigational drug outside this study within 30 days or 5 half-lives, 
whichever is longer, preceding the first dose of study medication. 
19. Have other concurrent malignancy (subjects with treated squamous cell carcinoma of 
the skin or basal cell carcinoma of the skin may be included), evidence of 
extrahepatic cancer from their primary malignancy, or ongoing, medically significant 
active infection. 
20. HIV positive. 
21. NYHA class III or IV functional classification for heart failure.  
22. Evidence of hemachromatosis. 
 
6.2.4 
Potential Risks and Benefits 
Potential Risks 
There are risks to subjects participating in this study. As reviewed in Sections 3.2 and 8.4, 
there are risks associated with the RFA procedure. There are also risks associated with the 
use of doxorubicin HCl.  Based on the clinical experience to date, there does not appear to be 
a substantial unique risk for ThermoDox, but unexpected AEs could occur. The RFA 
procedure itself has a relatively low major complication rate. The safety profile of RFA is 
provided in Sections 3.2 and 8.4. Doxorubicin HCl, the active agent in ThermoDox, is 
routinely given in chemotherapy regimens for multiple cycles after appropriate recovery 
intervals, usually at least 3 weeks. In contrast, the vast majority (84.8%; 291/343) of subjects 
in the RFA plus ThermoDox arm in the prior trial received only a single dose of 50 mg/m2 of 
ThermoDox.  
 


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The primary toxicities of doxorubicin are myelosuppression and cumulative-dose cardio-
toxicity. The risk of developing impaired ventricular ejection fraction (LVEF) is generally 
proportional to the cumulative exposure. The probability of developing cardiomyopathy 
isestimated to be 1 to 2% at total cumulative dose of 300 mg/m2 of doxorubicin HCL. (Pfizer 
Doxorubicin HCL Prescribing Information). The clinical safety profile of ThermoDox as 
observed to date is consistent with the known safety profile of doxorubicin HCl. Subjects in 
this study must have reasonable marrow reserve and adequate cardiac function. Subjects with 
prior doxorubicin exposure are excluded from this study (except in the case of completion of 
treatment or re-treatment). Expected non-hematological toxicities include cardio-toxicity, 
neuropathy, volume retention, hypersensitivity, mucositis, GI disturbances, nausea, and 
vomiting. Local toxicity in the liver will be carefully evaluated. Renal function will be 
closely monitored with urinalysis. BUN/Urea and creatinine will be monitored as 
nephrotoxicity has been seen in previous animal studies.  
 
The protocol does not require dose reduction in patients with elevated bilirubin. Dose 
adjustment for doxorubicin-containing chemotherapy was based on data from Benjamin, et 
al. (1974). However, an indiscriminate dose reduction based solely on serum bilirubin 
concentrations may not only reduce doxorubicin myelosupression but also the therapeutic 
outcome (Donelli, et al. 1998; Johnson, et al. 1986).  In the prior study, subjects with baseline 
serum bilirubin > 2.0 mg/dL had a higher incidence subsequent grade 3+ hyperbilirubinemia 
and of grade 3+ hepatic failure. However, the greater incidence of hepatic failure consisted of 
a single patient with grade 3 liver failure. Among patients with an elevated bilirubin level at 
baseline, there were no subsequent serious hepatobiliary adverse events except for 2 cases of 
hyperbilirubinemia/blood bilirubin increased. The DMC is responsible for unblinded 
monitoring of subjects with elevated (> 2.0 mg/dL and < 3.0 mg/dL) serum bilirubin levels 
and will advise if any dose or protocol modification is needed to mitigate risk to such 
patients.  
 
Doxorubicin imparts a red coloration to the urine for 1 to 2 days after administration.  
Subjects should be advised that this is expected. 
 
Dose adjustments are recommended in study patients who demonstrate significant 
myelosuppression from the initial dose of ThermoDox.  Guidance on dose adjustment in 
patients receiving additional treatment of study drug is provided in section 8.5.4 of this 
protocol. Among patients requiring re-treatment after incomplete initial ablation who have 
developed a non-hematologic toxicity > grade 3, no dose modification is required. Instead, 
such subjects will not be re-treated until the severity of the non-hematologic toxicity drops to 
< grade 2. 
 
It is possible that the concomitant use of ThermoDox with RFA may produce larger than 
usual ablation volume post-RFA. Liposomal doxorubicin has been observed to increase 
ablation volume, seemingly by sensitizing the tissue peripheral to the ablation margin to 
thermal injury and, therefore, effectively reducing the temperature threshold for ablation 
(Goldberg, et al. 2002). However, any relative increase in ablation volume is expected to be 
achieved in a controlled manner, since the ThermoDox-related enhanced release of 
doxorubicin will occur in the immediate region surrounding the RFA zone. There are 


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potential risks and benefits from this possibility; however, it has not been an apparent clinical 
problem in subjects treated to date with ThermoDox or in reports of combination of RFA and 
Doxil®, a non-heat-sensitive liposomal formulation (Goldberg, et al. 2002).  
 
Twenty five to thirty percent of subjects are at risk of developing a "post-ablation syndrome" 
with flu-like symptoms that in most cases appear three to five days after the RFA procedure 
and usually last about five days, although some subjects may remain ill for two to three 
weeks. Subjects with post-ablation syndrome may present with fever, delayed pain, malaise, 
chills, nausea after the procedure, even if only briefly (Dodd, et al. 2005), and transient 
elevation of transaminases. Oral acetaminophen is commonly given to control fever, which is 
the most common symptom. However, treatment of post-ablation syndrome should be based 
on the best judgment of treating physician. All subjects are required to undergo evaluation of 
their vital signs at specified time points after the ablation procedure. 
 
AASLD treatment guidelines permit diagnosis of HCC with the use of imaging only and 
without a biopsy for histological or cytological confirmation of disease. Completion of a 
biopsy sample increases risk to subjects with liver disease and therefore is not always 
indicated. However patients who undergo an RFA treatment without a biopsy may be at 
increased risk for undergoing an unnecessary ablation or be at risk for seeding for 
subcapsular or poorly differentiated disease. This risk is minimal and accepted within clinical 
practice guidelines. 
 
RFA has been used safely in tumors up to 7 cm (Chen, et al. 2004; Curley, et al. 2004; Dodd, 
et al. 2001; Tateishi, et al. 2005). In the United States and other local regions, palliative 
treatments such as transcatheter arterial chemoembolization (TACE) and sorafenib are the 
standard of care for HCC tumors > 5 cm. However, in this study the combination of RFA and 
ThermoDox is being investigated as a curative treatment for patients with tumors > 5 cm to < 
7 cm rather than for their palliation. There is risk that RFA is not as effective in the larger 
tumors, however this has not been established. Subjects are eligible to receive palliative 
therapy as medically indicated after progression is observed. 
 
There is a low but definite risk of hemorrhage in the liver or the peritoneal cavity following 
RFA procedure (Berber, et al. 2004 and 2007). After treatment, subjects will be monitored 
closely for at least one day and immediate interventional back-up, i.e., transcatheter arterial 
embolization or surgery, will be available at each study site in accordance with study site’s 
standard of care. Any adverse event must be monitored and recorded.  
 
There is a risk of infusion reactions with ThermoDox since such reactions to the IV 
administration of liposomal drugs have been previously reported. Severe infusion reactions in 
animals have been reported with ThermoDox in unprotected and less than optimally protected 
animals. A summary of this experience is provided in the non-clinical pharmacology and 
toxicology section of the Investigators brochure (IB).  Celsion’s approach to this has been to 
provide protection through broad-spectrum prophylaxis using steroids and antihistamines. 
 
IV contrast should not be administered if medically contraindicated. Subjects that meet the 
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undergoing  CT with contrast procedures. Investigators must be mindful of the risk factors 
associated with CIN and employ strategies to reduce the risk of CIN. In subjects with 
diabetes or borderline renal function (creatinine > 1.5 mg/dL), special precautions guided by 
the locally accepted medical standards (e.g., hydration, contrast dose reduction, follow up 
creatinine determination) should be employed. An accepted procedure may include adequate 
intravenous volume expansion with isotonic saline (1.0 – 1.5 mL/kg per hour) for 3-12 hours 
before the procedure and continued for 6-24 hours if clinically indicated and based on the 
treating physician’s medical judgment. 
 
Potential Benefits 
It is expected that thermal ablation of a subject’s liver lesion may result in local disease 
control and improved survival duration. The addition of ThermoDox to this ablation 
procedure has the potential to improve local control by the creation of high local 
concentrations of doxorubicin in the boundary of the ablation margin resulting in increased 
ablation volume and better tumor cell kill in and around the tumor margin. Thus, ThermoDox 
has the potential to enhance the local effects of RFA procedures. However, as an 
investigational product, it is not known at this time if ThermoDox will have a clinical benefit.  
 
 
7. 
ENROLLMENT AND WITHDRAWAL PROCEDURES 
7.1 Enrollment Procedures 
The Investigator must inform each prospective subject of the nature of the study, explain the 
potential risks, answer questions, and obtain written informed consent from the subject prior 
to performing any study-related screening procedures or assessments. The subject must also 
give consent, in verbal and/or written form, as directed by the ethics committee and/or local 
law. After written informed consent has been obtained, screening procedures for 
determination of eligibility can be initiated.   
 
Once screening procedures have been completed, the site will use a centralized 
randomization procedure in order to assign subjects to treatment with RFA plus ThermoDox 
or RFA plus dummy infusion.   
 
7.2 Subject Discontinuation 
Subjects will be discontinued from the study if they withdraw consent.  
 
Following progression, sites are instructed to contact subjects at 3-months intervals. At each 
follow-up interval, if contact cannot be made on the first attempt, then the site MUST 
document 3 attempts to contact the subject using phone calls or visits to the physician’s 
offices. If the site is unable to contact the subject, then a “certified or tracking letter” MUST 
be sent to the subject’s last known residence. This method of contact should be attempted at 
3 consecutive follow-up intervals prior to the subject being considered lost to follow up.   
 
If a subject discontinues from retreatments or from the PFS imaging interval, the patient 
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7.3 Study Noncompliance 
All instances of noncompliance and all significant protocol violations will be reported to the 
appropriate ethics committee per local regulations. All instances of eligibility violations or 
deviations will be recorded on the case report forms and reported to Sponsor. 
 
If a subject is discontinued from the study due to noncompliance of follow up visits, the 
patient should still be contacted for overall survival until end of study or withdraw consent 
from study participation. 
 
7.4 End of the Study 
The primary analysis will be based on the first 197 events (deaths) observed. Survival 
follow-up will be continued for 5 years after the last patient is randomized, to enhance OS 
evidence for regional or other subgroup assessments.   
 
 
8. 
STUDY TREATMENT ADMINISTRATION 
8.1 Allocation to Treatment 
Eligible subjects will be randomized through an Interactive Response Technology (IRT) 
web-based system. Subjects will be randomized in a 1:1 ratio to either the active treatment of 
ThermoDox (50 mg/m2) or to the non-active dummy infusion. Both treatment arms will be 
administered in conjunction with standardized RFA using a ≥ 45 minute treatment dwell 
time. The IVR system will advise the unblinded site representative (i.e. pharmacist) the 
treatment arm the subject has been randomized to and the kit number to dispense the pre-
medication (oral capsule) to the subject. Therefore, randomization must occur at least 24 
hours prior to the scheduled RFA procedure. 
 
A centralized computer-generated randomization scheme has been prepared before the study 
and controlled by the unblinded Sponsor representative. Subjects will be stratified by 
maximum lesion diameter (≥ 3.0 to 5.0 versus > 5.0 to ≤ 7.0) and RFA route (laparoscopic, 
open surgical, percutaneous).   
 
The Sponsor will provide all masking materials to maintain the blind. Each center will have 
identified unblinded representatives (i.e., pharmacist) to prepare the materials and to cover 
IV bags and tubing. Only designated Sponsor representatives may be unblinded as well.  
 
8.2 Pre-Medication and ThermoDox Administration 
Please refer to Pharmacy Manual for preparation and administration details. 
ThermoDox is calculated using Boyd’s formula as indicated in the Manual.  Accurate 
records must be kept regarding calculation and dispensing of study medication for each 
individual subject in the study. 
 


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Subjects assigned to the ThermoDox arm will be assigned a steroid, H1, and H2 
antihistamine pre-treatment regimen and subjects assigned to dummy infusion arm will 
receive non-active pre-treatment regimen in a blinded fashion.  
 
Oral premedication is supplied to the site as over encapsulated dexamethasone (20 mg/m2) 
capsules OR identical dummy capsules. Oral pre-medication is a single dose taken by the 
subject 24 hours (+/- 2 hours) prior to the scheduled study drug infusion.  
 
The day of the RFA procedure, subjects are required to be administered an IV premedication 
regimen according to local medical practice or as noted in the pharmacy manual. The IV 
premedication should be administered within 30 minutes (+15 min.) prior to the start of the 
ThermoDox infusion. The following may serve as a guide: 
• Dexamethasone 20 mg IV or dummy infusion of Sodium Chloride 0.9% or 5% 
Dextrose (D5W) 
• Diphenhydramine 50 mg IV (chlorpheniramine 10 mg IV is permitted) or dummy 
infusion of Sodium Chloride 0.9% or 5% Dextrose (D5W)  
• Ranitidine 50 mg IV or famotidine 20 mg IV or dummy infusion of Sodium Chloride 
0.9% or 5% Dextrose (D5W) 
 
These drugs are to be administered intravenously in the listed order. Intravenous 
premedications are secured using local formulary or matching dummy infusion of Saline or 
D5W. The premedications should not be mixed in the same bag. The unblinded study 
representative will prepare the pre-medications consistent with the randomized treatment 
arm so that other study personnel remain blinded.  
 
The total 250 cc volume of ThermoDox (50 mg/m2) or masked dummy infusion is delivered 
in a single 30-minute period through a free flowing IV line. The entire content of the infusion 
bag must be administered.  
 
RFA will be initiated at minute 15 (+5 minutes) following the start of study drug infusion 
and should be completed within 3 hours after study drug infusion initiation. The RFA 
procedure should achieve a dwell time of ≥ 45 minutes, which can be done by employing at 
multiple ablation cycles or deployments.   
 
 
 
 
 
 
 
 
 
 
 
 


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Figure 1:  Flowchart of Study Drug Administration in Relation to RFA 
-24 hours (+/- 2 hrs.)  
Subject takes oral premedication 
             ↓ 
 
 
 
           ↓ 
-30 min. (-15 mins) 
 
  Administer IV premedication 
             ↓ 
 
 
 
           ↓ 
  Timepoint 0 minutes  
  Start IV study drug infusion 
             ↓ 
 
 
 
           ↓ 
   At 15 min. (+5 min)                    Begin RFA Procedure 
 
 
             ↓ 
 
 
 
               ↓ 
 
  At 30 minutes 
 
Complete IV study drug infusion 
 
 
             ↓ 
 
 
 
               ↓ 
 
  + 60 minutes  
      Provide > 45 min. RFA heating time 
             ↓                                                        ↓ 
 <  180 minutes 
                     Complete RFA Procedure 
 
 
8.3 Use of Radiofrequency Ablation Devices  
Only FDA approved RFA devices including the Covidien switchbox and all manufacturer 
probes for these devices are permitted for this trial. The choice of RFA devices 
(Angiodynamics, Boston Scientific, or Covidien) will be made at each institution. Physicians 
(Principal Investigator or sub-Investigator) performing RFA may use more than one RFA 
device at their local institution. However, the same device must be used for all treatments of 
an individual patient.   
 
8.4 Radiofrequency Ablation Procedure  
The goal is to reach a ≥ 45 minute dwell time which can be achieved by employing multiple 
ablation cycles or deployments in order to ablate the tumor as well as a 360º 1.0 cm tumor-
free margin surrounding the tumor. Tumor uptake of ThermoDox is enhanced with a 
standardized RFA treatment dwell time of ≥ 45 minutes (≥ 30 minutes with a switchbox). An 
sRFA treatment for this protocol is defined as the dwell time of ≥ 45 minutes measured from 
the first activation of the RFA probe to produce coagulative necrosis of target tissue through 
removal of the RFA probe after the final ablation cycle or deployment. This includes the 
multiple ablation cycles and repositioning time between cycles for an individual patient. An 
ablation cycle for this protocol is defined as the single activation of the probe or electrode in 
order to achieve a local coagulation necrosis in target tissue. The cycle may be completed by 
achieving a target temperature in the tissue or a target impedance.  
The RFA operator must have experience with performing at least 15 procedures. A minimum 
of 5 prior cases with the device should be documented.   


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The standard RFA procedures to achieve adequate dwell time of ≥ 45 minutes must be 
implemented by the sites. 
a. The tumor should be treated with the goal of reaching a > 45 minute dwell time 
which can be achieved by employing multiple overlapping ablation cycles 
(according to literature recommend 4 cycles) thus ablating the tumor as well as a 
360° 1.0 cm tumor-free margin around the tumor. 
b. Devices should be operated within manufacturer’s instructions. 
c. A percutaneous, laparoscopic, or open surgical approach may be utilized. 
d. The RFA device operator will activate the RFA generator to initiate tumor tissue 
ablation temperatures at 15 minutes (+5 min.) after the start of the study drug 
infusion.  
e. Enhanced local concentration of doxorubicin and tumor uptake from ThermoDox 
requires at least 45 minutes RFA dwell time. This dwell time is achieved by 
administering multiple ablation cycles, so 4 ablation spheres (if using a simple 
needle electrode) or 4 deployments (if using multiple array LeVeen needle 
electrode) are recommended, but fewer or more may be performed at discretion of 
the investigator provided the dwell time reaches 45 minutes. The RFA literature 
recommends a minimum of 4 ablation cycles to ablate tumors of ≥ 3.0 cm 
together with a 360º 1.0–cm margin (Chen, et al. 2004). More ablations may be 
performed at the discretion of the operator (Curley, 2001; Dodd, et al. 2001; 
Chen, et al. 2006).  
f. Investigators are to follow their chosen RFA device’s particular guidelines for 
overlapping ablation procedures (See Appendix IV). 
g. Operators should employ strategies for maximal patient safety based on tumor size 
and tumor location (Rhim, et al. 2001). 
h. The procedure must be completed within 3 hours from the start of the infusion. 
i. The adequacy of ablation will be monitored by ultrasound, MRI, or CT scan 
throughout the procedure in accordance to the site’s standard of practice. 
j. Pringle maneuver or balloon occlusions are prohibited. 
 
RFA will be performed in accordance with RFA Treatment Procedure described in Appendix 
IV and manufacturer’s instructions provided separately.  
 
In order to avoid potential heating or burns to the skin area in contact with the grounding 
pads, handling of the skin area around the pads as well as the number of pads used will be 
determined per the RFA device manual’s instructions. Should the temperature of the ground 
pads rise above 39°C, the RFA treatment will be discontinued until the temperature returns to 
baseline; additional grounding pads can be employed to avoid skin burns and rising 
temperature. 
 


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8.5 Dose Modifications 
8.5.1 
Hepatobiliary Surveillance 
Subjects with an elevated serum bilirubin level (> 2.0 and ≤ 3.0 mg/dL) at baseline will have 
additional safety assesments at Day 7 post-ablation and at any other time the physician deems 
it necessary. These assessments should include a physical exam, vital sign, AE and 
concomitant medications assessment, and a CBC, UA and chemistry laboratory draw.  Grade 
3 – 4 hepatic toxicities are to be followed until resolution. 
 
No dose modification is required for patients with elevated serum bilirubin. 
 
8.5.2 
Suggested Management for Hypersensitivity Reactions: 
 
8.5.3 
Extravasations  
Infusion of ThermoDox should be closely monitored for local site reaction. If there are initial 
signs of extravasation, then the infusion must be immediately stopped and continued in 
another vein. Local protocol should be used to treat the affected area. Application of ice over 
the site of extravasation for approximately 30 minutes may be helpful in alleviating the local 
reaction. 
 
8.5.4 
Dose Modification for Re-Treatment ONLY 
Among patients requiring re-treatment after incomplete initial ablation who have developed 
Grade 4 hematologic toxicities, the absolute neutrophil and platelet counts must return to less 
than or equal to grade 1 before re-treatment.   
Severity of Symptoms: 
Treatment Guidelines: 
Mild Symptoms:  
localized cutaneous reactions such as mild 
pruritis, mild flushing, and mild rash.  
(Grades 0-1) 
• Consider decreasing the rate of infusion until 
recovery from symptoms, stay at bedside and 
monitor subject. 
• Then, complete study drug infusion at the 
initial planned rate. 
Moderate to Severe Symptoms:  
any symptom that is not mild (see above) such 
as generalized pruritis, generalized flushing, 
generalized rash, dyspnea, hypotension with 
systolic BP < 80 mm Hg, bronchospasm, 
angioedema and generalized angioedema. 
(Grades 2-4) 
• Stop infusion. 
• WITHDRAW FROM STUDY 
TREATMENT 
Anaphylaxis (Any degree of anaphylaxis): 
(Grade 4) 
• Stop infusion. 
• WITHDRAW FROM STUDY 
TREATMENT 
 


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The investigator should follow local/institutional cytokine support or in the absence of local 
guidelines for cytokine support, the investigator may use the “American Society of Clinical 
Oncology 2006 Update of recommendations for the use of white blood cell growth factors: 
An Evidence-Based Clinical Practice Guideline” (Smith et al. 2006). The second ablation 
must occur no later than 21 days after the first post-ablation radiographical imaging 
assessment at Day 28. If the patient does not meet the dose modification criteria within the 
timeframe, then patient should be taken off study and treated as clinically necessary. 
 
HEMATOLOGICAL TOXICITY* 
GRADE 
ANC 
PLATELETS 
MODIFICATION 
 
1 
1500-1900 
75,000-150,000 
Resume treatment with no dose 
reduction 
2 
1000-<1500 
50,000-<75,000 
Wait until ANC ≥ 1,500 and 
platelets ≥ 75,000; redose with no 
dose reduction 
3 
500-<999 
25,000-<50,000 
Wait until ANC ≥ 1,500 and 
platelets ≥75,000; redose with no 
dose reduction 
4 
<500 
<25,000 
Wait until ANC ≥ 1,500 and 
platelets ≥ 75.000; redose at 25% 
dose reduction or continue full 
dose with cytokine support 
*Dose reduction guidelines to investigators for subjects who experience Grade 4 absolute neutrophil counts 
(ANC) or Grade 4 platelet count and require additional ablation due to incomplete ablation 
Among patients requiring re-treatment after incomplete initial ablation who have developed a  
non-hematologic toxicity > grade 3, no dose modification is required. Instead, such subjects 
will not be re-treated until the severity of the non-hematologic toxicity drops to < grade 2. 
 
 
9. 
STUDY MEDICATION 
The Sponsor has prepared a Pharmacy Manual for further description of 
premedication and ThermoDox treatment dose preparation. The active pharmaceutical 
ingredient (API) in ThermoDox is doxorubicin hydrochloride for injection, USP. 
Doxorubicin is a cytotoxic anthracycline antibiotic. The investigational product ThermoDox 
combines doxorubicin HCl with a lyso-thermosensitive liposomal carrier. Staff must be 
properly delegated and trained to handle, prepare, instruct the subject, and administer the 
investigational product.  
 


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9.1 Clinical Supplies 
ThermoDox will be supplied as 15 mL clear vials containing 2 mg/mL doxorubicin. Multiple 
vial packaging will be supplied to the sites. The appearance of ThermoDox requires masking 
to maintain the blind of the study, therefore matching dummy vials will not be supplied for 
the trial. All treatment medication and premedication will be masked by the pharmacy in 
order to maintain blinding. 
 
The pre-treatment kits will contain over encapsulated Swedish orange opaque size DB AA 
capsules containing Dexamethasone 20 mg (5) 4 mg tablets or dummy tablets.   
 
Intravenous premedications are secured using local formulary or matching dummy infusion 
of Sodium Chloride 0.9% or 5% Dextrose (D5W). The Sponsor may procure and ship IV 
premedications to site if there are local regional formulary restrictions. 
 
Only subjects that sign informed consent and are randomized in the study may receive the 
investigational study medication (ThermoDox or dummy infusion), in accordance with all 
applicable regulatory requirements. 
 
9.2 Packaging and Labeling 
The vial of ThermoDox for Injection will be labeled Caution: New Drug Limited by Federal 
Law to Investigational Use Only, as presented below (or as required by local regulatory 
authority). 
Randomization identifiers will be placed on active and dummy pre-medication kits to guide 
the randomization process. 
 
Sample Label: 
 
 


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9.3 Storage of Study Medication 
ThermoDox must be stored frozen at colder than -60°C as per the manufacturer label. All 
Sponsor supplied investigational product must be kept in a secure area with access limited to 
the Investigator and authorized site staff. Storage conditions must be monitored for 
temperature deviations using a freezer with an appropriate monitoring device.  
 
9.4 Thawing, Stability, and Reconstitution of ThermoDox 
ThermoDox vials must be thawed at room temperature for a minimum of 75 minutes prior to 
reconstitution with 250 mLs of 0.9% Sodium Chloride Injection USP or 250 mLs 5% 
Dextrose Injection USP (D5W). The site will remove the number of ThermoDox vials 
necessary for the dose based on the subject’s body surface area (BSA) from Boyd’s formula. 
Do NOT heat ThermoDox vials to speed up the thawing process. Accelerated thawing 
techniques are not permitted. After thawing, the vials are stable for 4 hours at room 
temperature (15°C to 30°C).  
 
ThermoDox vials must be thawed and diluted to a final volume of 250 mLs using sterile 5% 
Dextrose Injection, USP (D5W) or 250 mLs of sterile 0.9% of Sodium Chloride Injection, 
USP (Saline). The total volume of 250 mLs is infused over a 30-minute period through a free 
flowing IV infusion pump.  
 
ThermoDox should be infused at room temperature. Do not heat ThermoDox solutions 
above room temperature during administration. 
 
ThermoDox is supplied sterile and pyrogen free; aseptic procedures should be employed 
during preparation for administration. For detailed storage and preparation instructions, refer 
to the Pharmacy Manual that is provided to the pharmacist by Celsion.  
 
9.5 Drug Accountability/Disposition of Clinical Trial Supplies  
Drug accountability records are required to be maintained by the site for all clinical trial 
supplies. Used clinical supplies will be destroyed at the site in accordance with the site’s 
local processes.    
 
Unused clinical supplies will be destroyed in accordance with the site’s regulations only after 
completion of the study supplies reconciliation by the Sponsor’s monitor. 
 
If it is not possible to destroy unused clinical supplies, Celsion Corporation should be 
contacted in order to make alternative arrangements. 
 


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10. 
SCHEDULE OF STUDY PROCEDURES 
Table 1: Schedule of Study Evaluations 
 
Protocol  
Section 
Procedure/Test 
Screening
/ Baseline 
Treatment Period1 
Follow-Up Period  
Procedure Day 
Day 0 
Post-Procedure Visits 
(+/- 3 days) 
Safety and Efficacy Assessments 
-21 Days 
Pre-
Dose 
Time 
0 
RFA 
+ 15 
min. 
Post 
RFA 
Day 
72 
Day 
14 
Day 
28 
M5, M9, 
M13 or 
Progression3 
M17, M21, 
M25  
6 Month 
Interval 
after M25 
3 Month 
Interval after 
Progression 
Evaluation and Observations 
 
 
 
 
 
 
 
 
 
 
 
17.1 
Informed Consent 
X4 
 
 
 
 
 
 
 
 
 
 
 
10.1.3 
Demographics and 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
10.1.5 
Physical exam 
X 
 
 
 
X 
X 
X 
X 
X 
 
 
 
10.1.6 
Vital Signs 
X5 
X5 
 
 
X5 
X 
X 
X 
X 
 
 
 
10.1.7 
ECOG 
Performance 
X 
 
 
 
 
 
 
 
 
 
 
 
14 
Adverse Event 
Eval. 
X  
→ 
→ 
→ 
→ 
→ 
→ 
X6 
X6 
 
 
 
11 
Con. Med. Update 
X 
→ 
→ 
→ 
→ 
→ 
→ 
X 
 
 
 
 
Treatment Procedures 
 
 
 
 
 
 
 
 
 
 
 
8.1 
IRT System/ 
Randomization 
X7 
 
 
 
 
 
 
 
 
 
 
 
8.2 
Pre-Medication 
Regimen 
 
X8 
 
 
 
 
 
 
 
 
 
 
8.2 
IV Study Drug 
Infusion 
 
 
X9 
 
 
 
 
 
 
 
 
 
8.3-8.4 RFA Procedure 
 
 
 
X10 
 
 
 
 
 
 
 
 


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Protocol  
Section 
Procedure/Test 
Screening
/ Baseline 
Treatment Period1 
Follow-Up Period  
Procedure Day 
Day 0 
Post-Procedure Visits 
(+/- 3 days) 
Safety and Efficacy Assessments 
-21 Days 
Pre-
Dose 
Time 
0 
RFA 
+ 15 
min. 
Post 
RFA 
Day 
72 
Day 
14 
Day 
28 
M5, M9, 
M13 or 
Progression3 
M17, M21, 
M25  
6 Month 
Interval 
after M25 
3 Month 
Interval after 
Progression 
Safety Procedures/Lab Tests 
 
 
 
 
 
 
 
 
 
 
 
10.1.10 LVEF Monitoring 
X11 
 
 
 
 
 
 
X11 
X11 
 
 
 
10.1.9 
12-Lead ECG 
X 
 
 
 
X 
 
 
X 
X 
 
 
 
10.1.11 Serum pregnancy 
test 
X 
 
 
 
 
 
 
 
 
 
 
 
10.1.12 CBC with 
differential  
X 
 
 
 
 
X 
X 
X 
X 
 
 
 
10.1.12  Serum chemistry12  
X 
 
 
 
 
X 
X 
X 
X 
X 
 
 
10.1.12 PT/INR 
X 
 
 
 
 
X 
X 
X 
X 
X 
 
 
10.1.12 Urinalysis 
X 
 
 
 
 
X 
X 
X 
X 
 
 
 
Disease Assessment 
 
 
 
 
 
 
 
 
 
 
 
10.1.4 
Biopsy 
 
X13 
 
 
 
 
 
 
 
 
 
 
10.1.8 
Imaging14 
X 
 
 
 
 
 
 
X 
X 
X 
X 
 
15.2.1 
Overall Survival15 
 
 
 
 
 
 
 
 
 
 
 
X15 
 
1.  Retreatment – Subjects are eligible for one retreatment no later than 21 days after the Day 28 imaging scan. The retreatment must be the 
same (sRFA + dummy or sRFA + ThermoDox) as initially administered.  
2.   Day 7 Visit – Only subjects with a total bilirubin > 2.0 but ≤ 3.0 mg/dL must undergo the additional safety visit on Day 7 post-RFA.  
3.   Time of Progression – Month 13 visit assessments are required at time of disease progression, whichever occurs first within the first 13 
months. No further assessments required after progression is recorded 
4.   Informed Consent – Is required within 28 days prior to study drug infusion. Informed Consent should be obtained prior to any study-related 
procedure performed outside standard medical care and required only to evaluate for participation in this trial. 


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5.   Vital Signs – Assess screening vital signs prior to randomization and perform a pre-dose assessment the morning of the RFA procedure. 
Post-RFA vital signs should be assessed within 15 minutes after completion of study drug infusion, within 30 minutes and 1 hour (+/- 15 min.) 
after RFA procedure, then every 2 hours (+/- 15 minutes) until the subject is stable or discharged.  
6.  Adverse Event Evaluation – Assess adverse events (AEs) through Day 28 following study drug treatment. AEs after Day 28 evaluated as 
possibly, probably or definitely related to the study drug or the RFA procedure will be recorded at any point during the trial and are to be 
followed until resolution or the patient is clinically stable.  
7.   Randomization – Eligibility criteria must be assessed prior to randomization. Randomization must occur at least 24 hours prior to scheduled 
RFA treatment time to ensure that the oral pre-medication regimen can be started. 
8.  Pre-Medication Regimen - A blinded oral pre-medication capsule is dispensed after randomization with instructions to take the pre-
medication 24 hours (+/- 2 hours) prior to the scheduled RFA procedure time. Recommend a reminder phone call be made to the subject the 
morning prior to RFA treatment. IV premedication (active or dummy infusion) is administered within 30 mins. (+15 min.) prior to study drug 
infusion. 
9.  IV Study Drug Infusion – Infusion is intended to be 30 minutes in duration; however, the complete contents of the infusion bag must be 
infused. 
10.  RFA Procedure – 15 minutes (+5 min) after the start of study drug infusion, RFA is to be initiated and is to be completed within 3 hours of 
the start of study drug infusion. RFA procedure should achieve an RFA dwell time of ≥ 45 minutes. 
11.  LVEF Monitoring – LVEF monitoring is required at baseline, at Day 28, and at Month 13 or radiologic progression, whichever occurs first. 
Echocardiogram is preferred. MUGA scans are permitted if an echo cannot be completed; however, the same method of measurement must be 
used to evaluate LVEF in an individual subject.     
12. Liver Function Tests – Serum Chemistry and PT/INR will be assessed  at baseline, day 14, day 28, month 5, 9, 13, 17, 21, and 25 or time of 
progression, whichever comes first. Patients with elevated bilirubin at baseline will also be assessed at day 7. 
13. Biopsy –Subjects not meeting AASLD diagnosis should have histological confirmation of HCC prior to randomization. 
14. Imaging – CT or MRI imaging (abdomen, chest, and pelvis) is required; however, the same modality used at baseline must be used for all 
further imaging in an individual subject. Scans must be done within 21 days prior to initial treatment to confirm the presence of an evaluable 
lesion and at Day 28 to evaluate whether a complete initial ablation was achieved. Follow-up imaging will be done at months 5, 9, 13, 17, 21, 
and 25 (+/- 2 weeks), then at 6-month intervals (+/- 2 weeks) until radiologic progression is seen. For trial purposes, an imaging scan 
demonstrating progression must be recorded before beginning alternative treatment.                     
15. Overall Survival – All subjects will be contacted every 3 months after radiological progression for vital status reporting.   
 


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10.1 Study Procedures 
10.1.1 
Screening Overview 
Written informed consent must be obtained ≤ 28 days prior to initiation of treatment and 
before any procedures specifically for inclusion in the protocol are performed.  
 
Screening assessments will be performed after obtaining informed consent and within 21 
days prior to the initiation of treatment. Screening procedures will include a medical history, 
physical examination, vital signs, ECOG performance status, adverse event evaluation, 
concomitant medicine update, ECG, ECHO or MUGA for LVEF measurement, laboratory 
tests, and radiological imaging scans. Screening laboratory procedures may be repeated to 
assess eligibility parameters during the screening period. 
 
Screening assessment will be collected, reviewed and determined to be acceptable by the 
Principal Investigator prior to randomization and must provide sufficient time for the subject 
to begin the pre-medication regimen. Any change in health evaluated by physical exam or 
vital signs should be acceptable to the Investigator before study treatment is started.  
 
10.1.2 
Subject Numbering 
Each subject for whom written informed consent has been obtained will be assigned an eight-
digit subject number. The first four digits of the subject number will be the investigational 
site numbers. The remaining digits will be a number starting with 7001 for the first subject 
enrolled at the site and incrementing by “1” for each sequential subject. 
 
Never reassign patient numbers.  In the event that a subject withdraws from the study, the 
number assigned to that subject is retired and the next subject receives the next sequential 
number. 
 
10.1.3 
Demographics and Medical History 
Demographic data (date of birth, race, and sex) will be recorded up to 21 days prior to study 
drug treatment. Medical history including details of cancer and non-cancer history will be 
collected. 
10.1.4 
Disease History and Biopsy 
Data on the current malignancy will include: date of diagnosis and stage of cancer,  
 
The following information must be obtained to confirm HCC: 
1. The date and results of the HCC biopsy.  
2. If a biopsy was not performed or not confirmatory of HCC then  
• Patient must meet AASLD criteria of  
o Hypervascular with washout in the portal/venous phase (on CT) OR 
o AFP > 200 ng/ml (for detailed description see Appendix VIII) 
• Record the reason why biopsy not performed. 


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Subjects may be randomized without a biopsy if they meet American Association for 
the Study of Liver Disease (AASLD) criteria for the diagnosis of HCC (see Appendix 
VIII).  Subjects not meeting AASLD criteria for HCC will need a biopsy for confirming 
HCC prior to randomization. 
 
10.1.5 
Physical Exam 
Physical examinations will be conducted within 21 days for eligibility assessment prior to 
randomization. An important component of the physical exam is the accurate measurement 
of height (in cm) and weight (in kg). All pertinent findings will be recorded on the 
appropriate pages of the CRF. All changes relative to baseline considered to be clinically 
significant by the Investigator will be reported as AE’s and recorded in the CRF.   
 
The physical exam must be conducted at the following times: 
• Once within 21 days of RFA treatment (initial and any re-treatment). 
• Post RFA prior to discharge.  
• Day 14 (+/- 3 days) 
• Day 28 (+/- 3 days)   
• Month 5, Month 9, Month 13 (+/- 2 weeks) or disease progression, whichever 
occurs first 
• Day 7 (+/- 3 days) for subjects with elevated bilirubin  
 
10.1.6 
Vital Signs 
Vital signs, which include temperature (in Celsius), blood pressure, pulse rate, and 
respiration must be obtained. Vital signs must be collected in a position that is consistent for 
all time points for each subject and will be collected at the following times: 
• Once within 21 days of RFA treatment (initial and any retreatment) 
• Before administration of the investigational product. Note: subjects with a 
temperature or blood pressure outside the eligibility criteria at the pre-dose evaluation 
should NOT receive treatment with investigational product. 
• Within 15 minutes after completing study drug infusion and after RFA 
completion at 30 minutes (+/- 15 minutes), 1 hour (+/- 15 minutes), every 2 hours 
(+/- 15 minutes) until the subject is stable or discharged. 
• Day 14 (+/- 3 days) 
• Day 28 (+/- 3 days)  
• Month 5, Month 9, Month 13 (+/- 2 weeks) or disease progression, whichever 
occurs first 
• Day 7 (+/- 3 days) for subjects with elevated bilirubin   
 
 


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10.1.7 
ECOG Performance Status 
The Investigator will evaluate the patient’s ECOG performance status within 21 days prior to 
study treatment. 
 
10.1.8 
Imaging 
CT or MRI scans (Chest, Abdomen and Pelvis) will be done within 21 days prior to study 
treatment to confirm the presence of an evaluable lesion and at Day 28 to assess whether a 
complete initial ablation was achieved. Additional imaging will be done at months 5, 9, 13, 
17, 21, 25, then every 6 months (+/- 2 weeks) until disease progression is seen. The 
following requirements apply to imaging for this study: 
 
• The same modality and technique must be used for all scans of an individual patient. 
• Investigator-determined radiological progression must be documented prior to any 
non-study HCC treatment. Imaging follow-up should continue for subjects with 
clinical evidence of progression until radiological disease progression is confirmed 
before beginning any non-study cancer treatment. 
• The date of progression will be reported to the CRF. 
 
Once the PFS endpoint is met, no further CT and MRI scans are required for this study. 
 
For subjects with incomplete ablations who are re-treated a second time and complete 
ablation is achieved, the imaging studies will continue per protocol with Day 0 set as the date 
of the second ablation procedure. If the lesion cannot be completely ablated after the second 
treatment, then the subject will be considered a treatment failure. Such subjects will continue 
to be followed for adverse events through Day 28 following the re-treatment; they will also 
continue to be followed for OS every 3 months. 
 
10.1.9 
ECG 
Acquire an ECG (12 lead with paper printout) at the following time points in relation to study 
drug treatment: 
Pre-Treatment  
• Within 21 days prior to study drug infusion 
 
Post-Treatment 
 
• Once subject is stable after RFA procedure  
• Day 28 (+/- 3 days)  
• Month 5, Month 9, Month 13 (+/- 2 weeks) or disease progression, 
whichever occurs first 
 
The Investigator will comment on any changes considered to be clinically significant and 
report as an AE. All changes considered clinically significant after Day 28 should be reported 
as AEs and recorded in the CRF  if considered possibly, probably or definitely related. 


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10.1.10 ECHO/MUGA Scan for LVEF Monitoring 
A baseline echocardiogram (ECHO) must be carried out within 21 days prior to study 
treatment. Measurements with a MUGA scan are allowed if an echocardiogram cannot be 
performed; however, the same modality used at baseline must be used for follow-up. Follow-
up scans must be completed on Day 28 (+/- 3 days) and at Month 13 or at time progression of 
disease, whichever occurs first.   
 
A decrease of >10% in resting LVEF that becomes abnormal (lower than the institutional 
lower limit of normal ) should be further evaluated by repeat examination for subjects with  a 
total cumulative doxorubicin of  ≥300 mg/m2.  
 
10.1.11 Serum Pregnancy Test 
Women of child bearing potential must undergo a serum pregnancy test within 21 days prior 
to each administration of study drug. 
 
10.1.12 Laboratory Analytes 
 
Table 2: Laboratory Analytes 
 
Hematology 
Clinical Chemistry 
Urinalysis 
Hematocrit 
Sodium 
AST/SGOT 
pH 
Hemoglobin 
Potassium 
ALT/SGPT 
specific gravity 
RBC count 
Chloride 
Alkaline 
Phosphatase 
Protein 
WBC count 
Glucose 
Total protein Glucose 
Differential WBC 
count 
Urea 
nitrogen 
Albumin 
Ketones 
Platelets 
Creatinine 
Calcium 
Blood 
PT 
Total 
bilirubin 
AFP 
WBC/HPF 
INR 
 
 
RBC/HPF 
 
 
 
Crystals 
 
 
 
 


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The laboratory will perform evaluations of the analytes listed in Table 2 above. Evaluations 
should take place as follows: 
• Within 21 days prior to study drug infusion- Repeat laboratory analysis is 
permitted to evaluate eligibility prior to treatment. The repeat analysis results 
must meet the eligibility criteria prior to study drug infusion. 
• Day 14  (+/- 3 days) 
• Day 28 (+/- 3 days) 
• Day 7 (+/- 3 days) for subjects with elevated bilirubin  
 
Additional hematologic tests (CBC with differential) will be collected at months 5, 9, and 13 
or disease progression, whichever occurs first. 
 
Additional post-treatment liver function tests (Chemistry and PT/INR), will be collected at 
months 5, 9, 13, 17, 21, and  25 (+/- 2 weeks) or disease progression, whichever occurs first.  
 
10.2  Re-Treatment  
A subject who has an incomplete initial ablation is eligible for 1 retreatment procedure within 
21 days after the scan showing residual disease at Day 28. Subjects will be retreated only 
once with the same treatment assigned at randomization. Baseline safety evaluations must 
meet the eligibility parameters prior to a retreatment. The second ablation must occur  no 
later than 21 days after the first post-ablation scan assessment at Day 28. Such subjects will 
continue to be followed for AEs/SAEs through Day 28 after the second study drug 
administration. Subjects with a complete ablation after retreatment will be followed for all 
primary and secondary endpoints. If after 2 ablations the subject has local, distant 
intrahepatic, or extrahepatic HCC, then the subject will be considered a treatment failure and 
will have met the PFS endpoint. The subject will still be followed for OS.   
 
Among subjects who are not treatment failures, five repeat treatments may be permitted to 
treat a recurrent lesion or to treat newly-identified local or distant intrahepatic lesions at the 
Investigator’s discretion after the PFS endpoint is reported and with agreement from the 
Sponsor. The subject must be eligible for retreatment consistent with the safety eligibility 
criteria and will be retreated with the same randomized treatment. 
 
Subjects who develop extrahepatic lesions will have met the PFS endpoint and are no longer 
eligible for further protocol treatment; they will be followed for OS. 
 
10.3  Unscheduled Assessments and Early Discontinuation 
The Investigator may, at his or her discretion, arrange for a subject to have an unscheduled 
assessment(s), especially in the case of adverse events that require follow-up. If the subject is 
experiencing an adverse event considered by the Investigator to be possibly related to the use 
of study treatment, then an unscheduled visit should be performed. 
 
 


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If the subject is discontinued from participation within the first year for any reason, the 
Investigator must make every effort to perform Month 13 evaluations as described in Table 
1.  
 
 
11. 
CONCOMITANT MEDICATIONS 
Subjects may take any medication that is not restricted by the protocol and would not be 
expected to interfere with the intent and conduct of the study. Chronic medications should be 
dosed on a stable regimen, if possible. In the case of medications restricted by the protocol, 
adequate washout times must be observed. Please reference Appendix III for an explanation 
of washout times. All medications (including herbal preparations) at the time of screening 
and within 30 days prior to study drug treatment and other treatments taken by the subject 
during the study and up to 24 hours following treatment, including those treatments initiated 
prior to the start of the study (ICF signing), must be recorded on the Case Report Form.  
 
Subjects should receive full supportive care during the study, including transfusion of blood 
and blood products, and treatment with antibiotics, antiemetics, antidiarrheals and analgesics, 
as appropriate.  
 
Supportive medications may be administered during the course of study for toxicity at the 
discretion of the Investigator. Subjects with myelosuppression may require blood or platelet 
transfusions, filgrastim (or other colony stimulating factors), or other supportive care 
medications, all of which may be administered at the Investigator’s discretion. Antiemetics 
may be administered to control nausea and vomiting, and antidiarrheals may be prescribed 
for diarrhea. 
 
Liposomal drugs (Abelect™, Ambisome™, Nyotran™, etc.), or lipid-complexed drugs 
(fentanyl, etc.) or intravenous fat emulsions could change the pharmacokinetic profile of 
ThermoDox and should not be administered to study subjects while on the trial. Intravenous 
fat emulsions, except propofol, should be prohibited as instructed in Appendix III. 
 
Doxorubicin is a substrate of CYP3A4. The following medications are prohibited from the 
specified time-point before the first dose of study drug treatment: 
• Other anti-cancer therapy should not be given until Investigator determined 
radiological disease progression, at minimum 30 days after the last study 
treatment, or withdrawal from the study. Subjects who receive concurrent anti-
cancer therapy will be discontinued from the study. 
• Any other investigational drugs, from 30 days or 5 half-lives, whichever is longer, 
prior to the first dose of study treatment until Investigator determined radiological 
progression. Subjects should not start another investigational drug without 
discussion with the medical monitor. If an investigational drug is initiated, it must 
be a minimum of 30 days after the last study drug treatment (except in re-
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• Inducers and inhibitors of CYP3A4 – these may alter the metabolism of 
ThermoDox, as the drug is a substrate for CYP3A4. CYP3A4 inducers and 
inhibitors that are prohibited from screening through 30 days after the last study 
treatment can be found in Appendix III Prohibited Medications; 
• Certain herbal supplements are prohibited as listed in Appendix III.  
 
 
12. 
ASSESSMENT OF EFFICACY 
12.1 Primary Endpoint: Survival 
All patients will be monitored for survival by recording their visits during routine follow up 
for response to treatment.  The visits are scheduled to occur every four months from the first 
imaging study confirming complete ablation until month 25 or radiological progression, 
whichever comes first.  If patients have not demonstrated radiological progression at month 
25 then the imaging visit schedule is reduced to every six months until progression.   
Survival is confirmed at every imaging visit. 
 
Once radiological progression is confirmed then follow up for overall survival is required.  
Sites are required to confirm contact with the subject during either a clinic visit or a 
telephone contact every three months.  It is expected that subject follow up will be about five 
years. 
 
12.2 Secondary Endpoint: Progression Free Survival 
The protocol incorporates modified RECIST (mRECIST) developed for HCC clinical 
research as a basis to evaluate tumor response.  The mRECIST enables assessment of overall 
response by taking into account target lesion response, and presence or absence of new 
lesions.  A separate imaging manual and imaging training program has been developed for 
this study in order to ensure uniformity in imaging technique and imaging review in 
accordance with mRECIST.  
 
12.3 Baseline Assessment 
The baseline assessment must include a comprehensive evaluation of the chest, abdomen and 
pelvis.  The HCC tumor identified on the eligibility scan should be defined as target lesion 
and its longest diameter should be measured on the contrast-enhanced CT or contrast-
enhanced MRI scan. This measurement should reflect the overall longest tumor diameter, 
regardless of the presence of internal areas of spontaneous necrosis. In the study protocol, 
intermediate size is defined as a tumor lesion larger than 3.0 cm but not exceeding 7.0 cm in 
longest diameter. Since the study will recruit patients with solitary tumors and no evidence of 
vascular invasion or extrahepatic spread, the eligible size HCC lesion detected on the 
eligibility scan is expected to be the only target lesion. No additional target or non-target 
lesions should be detectable on the eligibility scan to allow enrollment in the study 


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12.4 Target Lesion Response and Local Recurrence 
The image acquisition protocols used for any post-baseline assessments should be consistent 
with the protocol used for the baseline eligibility scan.   Baseline images for treatment 
eligibility will be confirmed centrally before RFA treatment.  Investigator determined 
radiological confirmation of complete ablation will occur at one month post RFA. If initial 
RFA is incomplete then a second, and final, attempt may be made for a complete ablation for 
subject to stay on protocol.  Once a complete ablation is confirmed then patients are 
monitored radiologically until progression.  The imaging interval will be every four months 
until month 25 then every six months thereafter.  No imaging studies are required once 
progression is confirmed.  
 
The disappearance of any intratumoral enhancement in the target tumor lesion after treatment 
with study treatment will be classified as complete response (CR), while the persistence of 
any areas of intratumoral enhancement consistent with residual viable tumor will be 
considered as incomplete response (IR). Failure to achieve a CR after two RFA ± 
ThermoDox treatment sessions will be classified as treatment failure. Tumor recurrence 
detected within or around the target lesion after having achieved initial CR will be classified 
as local recurrence. Tumor recurrences will be defined as local if they are located 1 cm or 
less from the ablation margin 
 
12.4.1 
Response Criteria for Assessing Index Lesion 
PFS will be measured from the date of randomization to the first date on which one of the 
following occurs:  
 
• Death of any cause  
• Treatment failure (inability to achieve CR after two RFA ± ThermoDox treatment 
sessions)  
• Progression due to local tumor recurrence after initial CR  
• Progression due to distant intrahepatic tumor recurrence  
• Progression due to extrahepatic tumor recurrence  
 
Disease progression will be assessed locally at each study site. CT or MRI scans (chest, 
abdomen, and pelvis) will be done at baseline and post-treatment at months 1, 5, 9, 13, 17, 
21, 25, then every 6 months (+/- 2 weeks) until radiological progression is seen. The 
definitions below will be used to assess disease progression. All imaging scans must be 
submitted centrally. Progression must be documented prior to any non-study HCC treatment. 
 
 
 


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Table 3: Radiological Progression Definitions 
 
Complete Response 
(CR): 
Complete disappearance of viable tumor on follow-up scan (Day 
28) when compared to the pretreatment images.  The ablation zone 
is defined radiographically as a homogeneous, avascular, non-
enhancing, sharply marginated ablation site following RFA 
evaluated on both arterial and portal venous phases and complete 
disappearance of the lesion. Ablation zones that are larger than the 
tumor (including a rim of surrounding liver parenchyma) are 
intentionally created to reduce the risk of local recurrence and are a 
much better predictor of actual complete ablation than is an ablation 
zone that is only equal in size to the native tumor. 
 
Incomplete Response 
(IR): 
Incomplete Response (IR): Any image-detected residual viable 
tumor at or within 1 cm of the ablation zone on Day 28 scan 
following initial ablation therapy that is smaller in size compared to 
pre-treatment scans, irrespective of the size of the zone of ablation.  
Incomplete responses will be allowed to be re-treated once.   
Local Recurrence 
(LR): 
Local recurrence (LR): Recurrence of viable tumor at or 
contiguous (within 1 cm) to the site of a prior ablation in the liver 
based on meeting one of any of the specific imaging criteria and 
features listed below when comparing the recent imaging (latest) to 
the reference imaging (Day 28 post-RFA, assuming complete 
treatment on Day 28 scan):  
• New soft tissue attenuation nodules that abnormally enhance 
and washout following intravenous contrast administration.  
• On subsequent scans at time points longer than 4-6 weeks 
after RFA: Presence of a measurable increase (at least 10 
mm) in size of the abnormally enhancing nodular soft tissue 
component within or adjacent to the treated tissue, as 
compared with baseline scan at approximately Day 28 post-
RFA.  
• A new HCC lesion or nodule signifying local recurrence is 
defined as a hypervascular lesion or nodule with abnormal 
enhancement and washout as defined above, and measuring 
greater than 10 mm in any axial dimension. 
• A lesion that does not show the prior typical features of 
HCC, but demonstrates serial enlargement of at least 10mm. 
  
Distant Hepatic 
Recurrence (DHR): 
Development of a new lesion (meeting the criteria described above 
for a new lesion) in the liver at a site greater than 1 cm from a prior 
ablation site, compared with nadir. 


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Extrahepatic 
Recurrence (EHR): 
Appearance of a new lesion outside of the liver.  Note: extrahepatic 
HCC lesions may not demonstrate the same enhancement criteria as 
indicated for intrahepatic lesions; however, they should be 
unequivocally malignant and new since nadir.  There are no size 
criteria. 
Unable to Evaluate 
(UE): 
A lesion present at baseline which was not measured or which was 
unable to be evaluated leading to an inability to determine the status 
of that particular tumor for the time point in question. 
Not Done (ND): 
Scans were not performed at this time point to evaluate the lesions. 
Equivocal (EQ) 
A new liver lesion that is smaller than 1 cm in longest diameter OR 
fails to show a typical enhancement profile should be considered as 
equivocal and not conclusive for disease progression. Such lesions 
can be diagnosed as HCC by evidence of either a change in 
enhancement pattern OR at least 1-cm interval growth in 
subsequent scans. 
 
 
 
Table 4: Overall responses for possible combinations of tumor responses in the target 
lesion with or without the appearance of new intrahepatic or extrahepatic lesions. 
 
Target 
Lesion 
Distant Intrahepatic 
Recurrence 
Extrahepatic Disease 
Overall Response 
CR 
No 
No 
CR 
IR* 
No 
No 
Treatment Failure 
IR* 
Yes 
No 
Progression 
IR* 
No 
Yes 
Progression 
Local Recurrence 
Yes or No 
Yes or No 
Progression 
Any 
Yes 
Yes or No 
Progression 
Any 
Yes or No 
Yes 
Progression 
*After 2 RFA +/- ThermoDox treatment sessions within 21 days after Day 28 radiological 
examination. 
 


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13. 
ASSESSMENT OF SAFETY 
Safety data will be tabulated for all subjects who were treated under the study protocol in 
either treatment group and will include vital signs, laboratory parameters, ECG, 
echocardiograms/MUGA, and adverse events. The Principal Investigator is responsible for 
recognizing and reporting adverse events during the conduct of the trial.  
 
A Data Monitoring Committee (DMC) will evaluate safety data on an ongoing basis at 
regular intervals during subject accrual and follow-up. The DMC is responsible for unblinded 
monitoring of subjects with elevated (> 2.0 mg/dL and < 3.0 mg/dL) serum bilirubin levels 
and will advise if any dose or protocol modification is needed to mitigate risk to such 
patients. The Sponsor is responsible to report relevant SAEs to applicable local, national, 
and/or international regulatory body. 
 
 
14. 
ADVERSE EVENTS  
An adverse event is defined as any unfavorable and unintended sign, including an abnormal 
laboratory finding, symptom, or disease temporally associated with the use of an 
investigational product, whether or not related to the investigational product. This includes 
any occurrence that was new in onset or aggravated in severity or frequency from the 
baseline condition. Adverse events (AEs) assessments will begin at time of signing of 
informed consent and will continue through Day 28 following study drug administration. 
AEs which are assessed as possibly, probably, or definitely related to study drug must be 
followed until resolution or until a stable clinical endpoint is reached.  
 
Other 
safety 
data 
including 
physical 
examinations, 
vital 
signs, 
ECGs, 
echocardiograms/MUGA scans, hematology, clinical chemistry, and urinalysis will be 
assessed through Day 28 following study treatment.  Subjects with an elevated serum 
bilirubin level (> 2.0 and ≤ 3.0 mg/dL) at baseline will have additional safety assessments at 
Day 7 post-ablation and at any other time the physician deems it necessary.  
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the following 
additional safety assessments will be done: 
• Physical examination, assessment of vital signs, ECGs, CBC with differential, serum 
chemistry, PT/INR and urinalysis at Month 5, Month 9, and Month 13 (+/- 2 weeks) or 
at disease progression, whichever occurs first. 
• LVEF monitoring at Month 13 or at disease progression, whichever occurs first 
• Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 25 (+/- 2 
weeks) or at disease progression, whichever occurs first. 
 
The condition which is detected by the diagnostic procedure conducted to test the efficacy of 
the investigational agent is not considered an AE.   
 


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Symptoms or clinically significant laboratory or instrumental (e.g., electrocardiographic) 
abnormalities of a pre-existing disease, such as cancer or other disease, should not be 
considered an AE. However, occurrence of new symptoms or laboratory or instrumental 
abnormalities, as well as worsening of pre-existing ones, are considered AEs.  
 
Abnormal results of diagnostic procedures, including laboratory test abnormalities, are 
considered adverse events if they result in:  
• Treatment or any other therapeutic intervention. 
• Further diagnostic evaluation (excluding a repetition of the same procedure to 
confirm the abnormality). 
• Associated clinical signs or symptoms that would have a significant clinical 
impact, as determined by the Investigator.  
 
Any untoward medical event that occurs from the time of signed informed consent to the 
time immediately prior to the first study drug administration will be reported as a “predose 
event” in the Medical History CRF. 
 
All adverse events that occur following study drug treatment will be documented on the AE 
CRF with indications of onset, duration, severity (NCI Common Terminology Criteria for 
Adverse Events), presumed relationship to study medication/RFA (not related, unlikely, 
possibly, probably, definitely), remedial actions taken, and outcome.  
 
An adverse event will be considered associated with the use of the study drug/RFA if the 
attribution was possibly, probably, or definitely. 
 
All subjects will be encouraged to report adverse events spontaneously or in response to 
general, open-ended questioning. All adverse events which are assessed as possibly, 
probably, or definitely related to study drug are to be followed up until resolution or the 
patient is clinically stable.   
 
Adverse events will be graded according to NCI Common Terminology Criteria for Adverse 
Events (CTCAE) Version 4.03  (See Appendix IX).  
 
14.1 Laboratory Test Results 
Clinically significant laboratory or instrumental (e.g., electrocardiographic) abnormalities of 
a pre-existing disease, such as cancer or other disease, should not be considered an AE. Any 
laboratory test result considered by the Investigator to be unusual, associated with clinical 
signs and/or symptoms, and clinically significant should be reported as an adverse event 
(clinically significant adverse events include those which require an intervention). Grade 3 
laboratory abnormalities meeting the above description should be recorded as AEs. All grade 
4 abnormal laboratory results must be recorded as AEs.  
 
Significant abnormal values occurring during the trial will be followed until repeat test 
results return to normal, stabilize, or are no longer clinically significant. Any positive 


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pregnancy test result must be repeated, study treatment withdrawn, and any pregnancy must 
be followed to term.  
 
14.2 Overdose 
Any instance of overdose (suspected or confirmed) must be communicated to the medical 
monitor within 24 hours of knowledge and be fully documented as a serious adverse event.  
An overdose should be evaluated by the Principal Investigator and potentially reported as an 
unanticipated problem to the site’s IRB according to local requirements.  
 
An overdose in which signs, symptoms, or abnormalities meet the definition of an adverse 
event or serious adverse event must be fully documented and reported consistent with AE 
and SAE reporting guidelines. Details of any signs or symptoms and their management must 
be recorded in the CRF. 
 
14.3 Non-Serious Clinical Adverse Events 
A non-serious adverse event is any AE that does not meet the criteria listed in section 14.4 
for a serious AE or the outcome (i.e., subject treatment, life-threatening condition, 
hospitalization, recovery) cannot be determined with the information provided. 
 
For detailed description of relationship of AE to study treatment refer to Appendix V. 
 
14.4 Serious Adverse Events (SAE) 
Serious adverse events are defined as any untoward medical occurrences that at any dosage 
results in one or more of the following:  
• Death. 
• Is immediately life-threatening, (i.e., presented an immediate risk of death at the 
time of the adverse event, not an adverse event that hypothetically might have 
caused death if it were more severe). 
• Requires or prolongs inpatient hospitalization. 
• Causes persistent or significant disability/incapacity. 
• Is a congenital anomaly/birth defect. 
• Significant medical event that requires intervention to prevent one of the above 
outcomes listed in the above definition  
 
Any SAE, which occurs after a subject has signed consent and until Day 28 following last 
study drug administration, whether or not related to study treatment, must be reported to 
Pharmacovigilance immediately (within 24 hours of knowledge of the event) via telephone, 
facsimile or email. If initially reported via telephone or email, this must be followed up by a 
facsimile of the written SAE report (within 24 hours of the initial telephone report).  
 
Country specific reporting requirements apply. For example, all China local SAEs during the 
study must be reported within 24 hours to the CFDA.  
 


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14.4.1 
Definition of Life-Threatening Adverse Experiences 
An adverse experience is life-threatening if the subject is at immediate risk of death from the 
event as it occurred; i.e., it does not include a reaction that, if it had occurred in a more  
severe form, might have caused death. For example, drug-induced hepatitis that resolved 
without evidence of hepatic failure would not be considered life threatening, even though 
drug-induced hepatitis can be fatal. 
 
14.4.2 
Definition of Disabling/Incapacitating Experiences 
An adverse experience is incapacitating or disabling if the experience results in a substantial 
and/or permanent disruption of the subject’s ability to carry out normal life functions. 
 
14.4.3 
Reporting of SAEs 
Any serious event, including death from any cause that occurs up to one month following last 
study treatment administration, whether or not related to the investigational drug or RFA, 
must be reported to Pharmacovigilance immediately (within 24 hours) via telephone, fax, or 
e-mail.   
 
If initially reported via telephone or e-mail, this must be followed-up by a written faxed 
report to be submitted within 24 hours of the initial report.   
 
 
Pharmacovigilance (SAE) contact phone numbers: 
 
InVentiv Pharmacovigilance 
 
Region 
North America 
Mainland China 
Europe & Rest of 
World 
Fax (SAE 
reporting) 
XXXXXXXXXX 
XXXXXXXXXX 
XXXXXXXXXX 
Email 
XXXXXXXXXX (NA)   
XXXXXXXXXXXXXXXXXXXXXXXXXXXXX (ROW/Asia Pac) 
 
 
Initial Reports 
Within 24 hours of the site’s knowledge of a serious adverse event: 
• 
Complete a Serious Adverse Event Report Form (SAER), sign it, and fax it to the 
Pharmacovigilance using the designated fax transmittal form.   
• Place the initial version of SAER in the subject’s file. 
 
 


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Follow-Up Reports 
New information received spontaneously or by request of the Medical Monitor or Safety 
Surveillance: 
 
Within 48 hours of the receipt of new information: 
• Complete a new SAER with the new information. Sign and fax the form to 
Pharmacovigilance.   
• Fax copies of supporting documents (e.g., hospital discharge summaries, lab test 
results with normal ranges, autopsy or biopsy reports) to Pharmacovigilance.  
• Place the follow-up version of the SAE and all supporting documentation in the 
subject’s file.  
 
Final Report 
Within 48 hours of the receipt of final information: 
• Determine that there is no further information available and this update may be 
considered final. 
• Complete a new SAER form with the new and final information. Sign and fax the 
form to Pharmacovigilance. As above, send copies of any additional supporting 
information. 
• Place this version of the final SAER into the subject’s file. 
 
It is imperative that Pharmacovigilance be informed within 24 hours of a serious adverse 
experience (including overdose with clinical effect, which is considered an SAE) so that 
reporting to the FDA and other regulatory agencies can be met within the required time 
frame (7 or 15 calendar days).   
 
Because of the need to report to health authorities all serious adverse experiences in a timely 
manner, it is vitally important that an Investigator report immediately any adverse 
experiences, which would be considered serious, even if the Investigator does not consider 
the adverse experience to be clinically significant or drug/RFA-related. 
 
Should the Investigator become aware of an SAE (regardless of relationship to study drug) 
that occurs while the subject is on the study, the SAE must be reported in accordance with 
the procedures specified in this protocol.  
 
If the subject is withdrawn less than 28 days after study drug treatment, any SAEs which 
occur within 28 days after study drug treatment must be reported in accordance with the 
procedures specified in this protocol.  
 
All serious adverse events that are assessed as possibly, probably, or definitely related to 
study drug are to be recorded at any point during the trial and followed until either: the 
adverse event resolves, the adverse event stabilizes, the adverse event returns to baseline 


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values (if a baseline value is available), or it is shown that the adverse event is not 
attributable to the study drug or study conduct. 
 
14.5 Other Events 
If a female subject becomes pregnant during the study, follow-up of the outcome of the 
pregnancy and any postnatal sequelae in the infant is required. Pregnancies are not 
considered SAEs but are considered immediately reportable (within 24 hours) and are to be 
documented on the Pregnancy Report form. 
 
Medical and scientific judgment is to be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as for important medical events that were not 
immediately life-threatening or did not result in death or hospitalization but are jeopardizing 
the subject or require intervention to prevent one of the outcomes listed above. 
 
 
15. 
STATISTICS 
A Statistical Analysis Plan (SAP) that includes a more technical and detailed description 
(including templates for Tables, Listings, and Figures) of the planned statistical summaries 
and analyses will be prepared. 
 
15.1 
Study Populations 
The safety and efficacy study populations will be defined as follows: 
• Intent-to-Treat (ITT) population: This population includes all randomized subjects 
and is the primary population for subject characteristics and all efficacy parameters. 
All analyses using this population will be based on the treatment to which each 
subject was randomized. 
• As-Treated (AT) population: This population includes all subjects who actually 
received at least one application of RFA plus ThermoDox (TR) or RFA + dummy 
infusion (PR).  This population will be used for the safety analyses. All analyses 
using this population will be based on the treatment actually received. 
 
15.2 
Study Endpoints 
15.2.1 
Primary Endpoint – Overall Survival (OS) 
Overall Survival is the primary endpoint of this study and is defined as the time (in months) 
from the date of randomization to the death date. In the absence of death confirmation or for 
subjects alive as of the OS cut-off date, survival time will be censored at the date of last 
study follow-up, or the cut-off date, whichever is earlier. 
 
The OS cut-off date used for the primary analysis will be based on the observations of the 
197th death in the study. With the OS cut-off date being event driven, for operational 


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efficiency, the cut-off date for all other study endpoints (e.g., PFS) will be fixed at close 
proximity of the OS cut-off date, when the milestone is nearing completion. 
15.2.2 
Secondary Endpoints 
15.2.2.1 Progression-Free Survival (PFS) 
Progression-free survival is defined as the time (in months) from the date of randomization 
until the date of the Investigator-assessed radiological disease progression or death due to 
any cause.  Subjects who are alive with no disease progression as of the analysis cut-off date 
will be censored at the date of the last tumor assessment. Subjects who receive non-study 
cancer treatment before disease progression, or subjects with clinical but not radiologic 
evidence of progression will be censored at the date of the last evaluable tumor assessment 
before the non-study cancer treatment is initiated. If a subject undergoes a liver transplant or 
liver resection before progression is observed, then the PFS for this subject will be censored 
on the date of last assessment without documented progression prior to the procedure. 
Treatment failures (subjects with incomplete ablations after two RFA procedures) will be 
considered to have met the PFS endpoint and the date of the Day 28 assessment following the 
2nd ablation procedure will be used as the progression date. Additional censoring rules details 
will be outlined in the SAP. 
 
15.3 
Statistical Analysis 
15.3.1 
Subject Disposition, Baseline and Treatment Characteristics 
15.3.1.1 Subject Disposition 
The number of subjects in each study population and the reasons for exclusion, along with 
any randomization and/or stratification errors will be summarized. In addition, subjects that 
discontinue study treatment or study follow-up will also be summarized, along with reasons 
for study discontinuation. 
15.3.1.2 Subject Baseline Characteristics 
Subject characteristics at Baseline will be summarized in frequency tables or with summary 
statistics for continuous variables.  
15.3.1.3 Study Treatment 
The study treatment administration and compliance profile will be summarized descriptively. 
15.3.1.4 Non-Study Treatment in the Study Follow-up Period 
The number, type, and extent of use of non-study cancer treatment after study treatment 
discontinuation will be summarized.   
15.3.2 
Efficacy Analyses 
15.3.2.1 Primary Efficacy Analysis 
OS in the ITT population will be compared between the 2 treatment groups using the 
stratified log-rank test. The estimate of the hazard ratio and corresponding 95% CI will be 
provided using a Cox proportional hazards (CPH) model including treatment and the 


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stratification factors (maximum lesion diameter [3-5 cm versus >5–7 cm] and RFA route 
[laparoscopic, open surgical, percutaneous]) in the model. The survival curves will be 
estimated using Kaplan-Meier estimates. The stratification factors will be populated as per 
the randomization assignment. 
15.3.2.2 OS - Supportive Analyses 
Supportive analyses for OS, conducted in the ITT population (unless otherwise noted), will 
include: 
a. The unstratified log-rank test and a CPH model (only treatment effect t in the model).  
b. Multivariate analysis using the CPH model, including the stratification factors and the 
following set of potential prognostic/predictive factors: age (< 65 v. ≥ 65), race 
(Caucasian, Asian, Other), region (EU and US, China, Korea, Other), baseline 
platelets, RFA start time, RFA dwell time (≤ 45 min – for any outliers, ≥ 45 min and 
≤ 90 min, ≥ 90 min), device, disease etiology (Hep B, Other).  
Factors included in the model will be assessed for co-linearity and a stepwise 
selection process will be applied to identify a final subset of prognostic/predictive 
factors in the model. Once the subset has been established, treatment will be added to 
the final model to assess its effect.   
An exploratory analysis of treatment by factor interactions using the CPH model will 
be conducted, using the factors identified in the final model above. 
c. Subgroup analyses will also be conducted for the stratification factors and the 
potential prognostic/predictive factors identified in Section 15.3.2.2.b above. The HR 
and associated 95% CI will be presented for each subgroup. 
d. The primary efficacy analysis, as outlined in Section 15.3.2.1, will also be run 
excluding any subjects that did not meet key eligibility criteria: a) single HCC lesion 
between ≥ 3.0 and ≤ 7.0 cm, b) ECOG performance status, c) RFA start time within 
20 minutes of starting the infusion, d) RFA dwell time ≥ 45 minutes, and e) baseline 
platelets ≥ 75,000/mm3 and f) Child-Pugh A classification. Additional sensitivity 
analyses will be defined in the SAP. 
 
15.3.2.3 Secondary Endpoint Analyses 
All secondary endpoints comparisons will be made at the 2-sided 0.05 significance level. 
Since PFS is the only secondary endpoint for regulatory registration purposes, no further 
multiplicity adjustments will be made. Assuming that OS demonstrates significance at the 1-
sided 0.025 level, PFS can subsequently be tested at the 1-sided 0.025 level.    
 
PFS will be analyzed with methodology applied to the OS endpoint. Specifically, PFS will be 
analyzed with the methodology specified in Section 15.3.2.1 and 15.3.2.2. Additional 
sensitivity analyses, as detailed in the SAP, will account for clinical progression as a PFS 
event.   
 


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15.3.2.4 Safety Analyses 
The safety evaluations will focus primarily on AEs and laboratory assessments, but will also 
include physical examinations, vital signs, ECGs, echocardiograms/MUGA scans 
hematology, clinical chemistry, and urinalysis beginning at time of signing of informed 
consent and continuing through Day 28 following study drug administration.. AEs after day 
28 visit which are assessed as possibly, probably or definitely related to study treatment will 
be recorded at any point during the trial. All subjects included in the As-Treated Population 
will be evaluated by treatment arm in the safety analysis. 
 
Adverse events will be coded according to the Medical Dictionary for Regulatory Activities 
(MedDRA) terminology and the severity of the toxicities will be graded according to the NCI 
CTCAE criteria, v4.03, where applicable.  Concomitant medications will be coded according 
to the World Health Organization (WHO) Medication Dictionary for Concomitant 
Medication. 
 
All AEs will be summarized (incidence) and listed by the System Organ Class (SOC), 
preferred term, toxicity/severity grade, and causal relationship to study medication. In 
addition, separate summaries of SAEs and Grade 3 and 4 AEs will be presented. 
 
Hematological and chemistry laboratory parameters will be graded according to the NCI 
CTCAE v.4.03 criteria, where applicable. Absolute values and changes from baseline will be 
summarized. In addition, worst severity grade, time to event, and time to resolution will also 
be summarized. 
 
15.4 
Determination of Sample Size 
15.4.1 
Study Population 
The study is designed to detect with 80% power a hazard ratio for OS of 0.67 (33% risk 
reduction) in the ThermoDox (TR) arm compared with the control (PR) arm with an overall 
1-sided type 1 error of 0.025. An OS hazard ratio of 0.63 was observed among HEAT Study 
patients with a solitary 3-7 cm lesion treated with ≥ 45 minutes of RFA. A 3%/year loss to 
survival follow-up rate has been assumed and using a 1:1 treatment allocation (TR:PR) of 
550 subjects, a target of 197 events (deaths) will be required for the primary analysis. 
 
Based on these design operating characteristics and assuming a median survival time of 
approximately 4.5 years in the control arm, the primary analysis target events milestone will 
be reached approximately 30 months after the last subject is randomized in the study. The 
median OS in the control arm was estimated based on the interim OS results in the HEAT 
study.   
 
15.5 
Interim Analyses 
An independent Data Monitoring Committee (DMC) will periodically assess the safety data. 
A description of the roles and responsibilities and details of the review processes are 
provided in a separate DMC charter.  


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Two interim analyses, both for efficacy and futility, are planned for the study. The first is 
planned after 60% of the target events is reached (118 deaths) and the second after 80% of 
the events has been reached (158 deaths). The Lan-DeMets alpha-spending approach will be 
used with O'Brien-Fleming stopping boundaries to evaluate efficacy. Fixed HR boundaries 
will be used to assess futility. This approach will account for multiple testing and preserve 
the overall 1-sided study significance level of 0.025. Additional details will be provided in 
the DMC charter. 
 
No futility analyses are planned during the accrual period. Considering the relative short time 
of the accrual period compared to the slower accumulation rate of the events, there will not 
be sufficient events to make such assessment in the accrual study stage. 
 
 
16. 
DATA HANDLING 
16.1 Direct Access to Source Data/Documents 
The Investigator and institution agree that Celsion, its representatives (includes CRO, 
auditors, and monitors), the IRB/REB/IEC, and representatives from worldwide Regulatory 
Agencies will have the right, both during and after the clinical trial, to review and inspect 
pertinent medical records related to the clinical trial. 
 
The Investigator must maintain the primary records (i.e., source documents) of each subject’s 
data at all times. Examples of source documents are subject progress notes, clinic notes, 
hospital records, laboratory reports, drug inventory, study drug label records, and those CRFs 
that are used as source documentation. 
 
The Investigator will maintain a confidential subject identification list that allows the 
unambiguous identification of each subject. All study-related documents must be kept until 
notification by Celsion instructs otherwise. 
 
16.2 Quality Control and Quality Assurance 
16.2.1 
Monitoring of the Study and Regulatory Compliance 
The project manager, or their monitor designee, will make an initiation site visit to each 
institution to review the protocol and its requirements with the Investigator(s), inspect the 
drug storage area, and fully inform the Investigator of his/her responsibilities and the 
procedures for assuring adequate and correct documentation. During the initiation site visit 
the case report forms (CRFs) and other pertinent study materials will be reviewed with the 
Investigator’s research staff. During the course of the study, the monitor will make regular 
site visits in order to review protocol compliance, examine CRFs and individual subjects’ 
medical records, and assure that the study is being conducted according to pertinent 
regulatory requirements. All CRF entries will be 100% verified with source documentation. 
The review of medical records will be done in a manner to assure that subject confidentiality 


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is maintained. Sponsor or Regulatory body inspections may occur as well to assure the 
accuracy of study conduct. 
 
16.2.2 
Curricula Vitae and Financial Disclosure of Investigators  
All Principal Investigators will be required to provide a current signed and dated curriculum 
vitae, a completed FDA Form 1572, and a financial disclosure statement to Celsion or their 
authorized representative. In addition, all Sub-Investigators will be required to provide a 
current curriculum vitae and a financial disclosure statement. 
  
16.2.3 
Protocol Modifications 
No modification of the protocol should be implemented without the prior written approval of 
the Sponsor or the Sponsor’s representative. Any such changes, which may affect a subject’s 
treatment or informed consent, especially those increasing potential risks, must receive prior 
approval by the IRB/REB/IEC. The exception to this is where modifications are necessary to 
eliminate an immediate hazard to trial subjects, or when the change involves only logistical 
or administrative aspects of the trial (e.g., change in monitor, change in telephone number).  
Other administrative revisions, which may affect the clinical portion of a study, will be duly 
reported to the IRB/REB/IEC by the Principal Investigator. 
 
16.3 Data Handling and Record Keeping 
The trial developed Case Report Form (CRF) is the primary data collection instrument for the 
trial. All subject data requested on the CRF must be supported by and be consistent with the 
patient’s source documentation. All missing data must be explained. When a laboratory test, 
assessment, or evaluation has not been performed or is “unknown”, a note should be created 
verifying that the field was “Not Done” or “Unknown”. For any entry error made, the errors 
must be corrected, and a note explaining the reason for change should be provided.    
 
Any electronic Case Report Forms (eCRF) system would be developed, maintained and 
utilized consistent with 21 CFR part 11 requirements. Authorized site personnel would 
require proper training on the system and would have an individual username and password 
to complete data entry and to address data clarifications. 
 
Any paper Case Report Forms will consist of two-part no-carbon-required paper (NCR) and 
should be completed in black ink (hard point pen). Incorrect data should not be obliterated. 
Use of white-out is prohibited. Any correction or deletion should be made by drawing a 
single line through the entry so that the original entry is still legible. This change must be 
initialed and dated by the site study coordinator or Investigator. The top sheet will be 
collected by the monitor. The bottom sheet is for the Investigator files and must be made 
available for review by Sponsor, IRB/REB/IEC, or appropriate regulatory agencies.  
 
Any changes made to data after collection will be made through the use of Data Clarification 
Forms (DCF). Data reported on the case report forms, which is derived from source 
documents, should be consistent with the source documents or the discrepancies should be 
explained. Case report forms will be considered complete when all missing and/or incorrect 


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data have been resolved. Please refer to the separate Case Report Form Completion 
Guideline for further instructions. 
 
16.3.1 
Data Collection 
Intraoperative data for device type, the number of ablation cycles, the RFA dwell time, probe 
type, tip length, and probe length will be documented.  
 
Note: A standard sRFA treatment is defined as the dwell time of ≥ 45 minutes measured from 
the first activation of the RFA probe to ablate tissue through turning off the RFA generator 
after the final ablation cycle. This includes the multiple ablation cycles and repositioning 
time between cycles for an individual patient. 
 
16.3.2 
Recording of Data 
The Investigator will be responsible for the recording of all data on the CRFs provided, as 
certified by the Investigator’s signature and date on the designated pages. Should any value 
be significantly different from normal, the Investigator or designee will comment in the 
appropriate sections provided in the CRFs. 
 
The Investigator will provide access to his/her original records to permit a representative 
from the Sponsor to verify the proper transcription of data. To facilitate photocopying, any 
paper CRF entries must be recorded legibly in black ink only. Erroneous entries will be 
crossed out with a single line, so as to remain legible. The correct value will be entered above 
the error and then initialed and dated by the person authorized to make the correction. 
 
16.3.3 
Study Records 
Investigators in the United States, Canada or EU must maintain all study records for the 
indication under investigation for two years following the date a Product Licensing 
Application is approved or, if no application is to be filed or if the application is not approved 
for such indication, until two years after the investigation is discontinued and the FDA is 
notified.   
 
Investigators in Asia must maintain all study records for the indication under investigation 
for five years following the date a Product Licensing Application is approved.    
 
Subject’s medical files should be retained in accordance with applicable legislation and in 
accordance with the maximum period of time permitted by the hospital, institution or private 
practice. Investigator must contact the Sponsor before moving or removing the study files. 
 
16.4 Financing and Insurance 
Financing and insurance information is provided for this study under separate cover. 
 


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16.5 Publication Policy 
Since the Phase III study is a blinded, randomized, international study for registration 
purposes, no individual Investigator may publish or disclose clinical trial results until the 
study is completed. Study completion is defined as FDA review and response of the NDA 
submission. In addition, Institution acknowledges that, due to the limited patient population 
in its treatment group, the data generated from its individual participation in the Study and 
evaluation of its individual results may not be sufficient from which to draw any meaningful 
scientific conclusions. 
 
Upon study completion, Institution may, upon written notice to Sponsor, participate in a 
joint, multi-center publication of the study results with other third party Principal 
Investigators and/or institutions, provided that the proposed publication is first reviewed, 
commented, and approved by expressed written consent by Sponsor.  
 
Sponsor will provide authorship rights (and lead authorship rights) to Phase III site 
Investigators in order of greatest contribution of evaluable patients to the Phase III 
registration study. The term “evaluable” is distinguished from “enrollment contribution” and 
defined as patients that the FDA accepts as patients qualified for NDA approval. In addition, 
Sponsor may form a publication committee to evaluate and give final approval of publication 
submission. 
 
At least sixty (60) days prior to submitting a manuscript to a publisher or other outside 
persons (i.e., reviewer[s] or prior to any public presentation), a copy of the manuscript or 
presentation will be provided to Sponsor by the Investigator for review and comment. The 
Investigator understands and agrees that participation in the Study may involve a 
commitment to publish the results of the Study in a cooperative publication with other 
Investigators prior to publication or oral presentation on an individual basis. No publication 
of confidential information shall be made without Sponsor’s prior written consent, which 
shall not be unreasonably withheld or delayed. The Investigator agrees, following a request 
from Sponsor, to delete any confidential information which would prejudice the securing of 
adequate intellectual property protection from the proposed publication. 
 
 
17. 
ETHICAL CONSIDERATIONS 
The study will be conducted in the US under Investigational New Drug (IND) 
Application 66,827, in compliance with Title 21 of the Code of Federal Regulations (CFR), 
Part 50 (Protection of Human Subjects), and Part 56 (Institutional Review Board) as well as 
the principles of the Declaration of Helsinki and its amendments and local country-specific 
requirements. Institutional Review Boards (IRBs) reviewed and approved the protocol and 
informed consent. All subjects will be required to give written informed consent prior to 
participation in the study. This study will be performed in accordance with Good Clinical 
Practices (GCP) by qualified Investigators. 
 
The study specifically incorporates the following features: 


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• Randomized study design 
• Blinding of subjects and Investigators 
• Parallel active control group 
• Prospectively stated objectives and analytical plan 
• Accepted, pre-specified outcome measures for safety and efficacy 
• Investigator meeting (and/or a site initiation visit) prior to study start and a 
detailed protocol to promote consistency across sites 
• Compliance with Good Clinical Practices (GCP), with assessment via regular 
monitoring. 
 
Quality assurance procedures will be performed at study sites and during data management to 
assure that safety and efficacy data were adequate and well documented. 
 
17.1 Informed Consent  
The Investigator will obtain written informed consent from each subject (or their authorized 
representative) participating in the study. The form must be signed, witnessed and dated 
according to local acceptable standards.  The informed consent form will contain all the 
Essential Elements of Informed Consent set forth in 21 CFR Part 50, and the ICH Guideline 
for Good Clinical Practice, Section 4.8 (see Appendix VIII), and the terms of the Declaration 
of Helsinki. Copies of the signed document should be given to the subject and filed in the 
Investigator’s study file, as well as the subject’s medical record if in conformance with the 
institution’s Standard Operating Procedures.  
 
17.2 Institutional Review Board/Research Ethics Board/Independent 
Ethics Committee 
The study will not be initiated without approval of the appropriate Institutional Review 
Board/Research Ethics Board/Independent Ethics Committee (IRB/REB/IEC) and will 
comply with all administrative requirements of the governing body of the institution. This 
protocol, consent procedures, and any amendments must be approved by the IRB/REB/IEC 
in compliance with current regulations of the FDA and in accordance with ICH/GCPs. A 
letter of approval will be sent to the Sponsor prior to initiation of the study and when any 
subsequent modifications are made. The Sponsor or their authorized representative will keep 
the IRB/REB/IEC informed, as required by regulations, of the progress of the study as well 
as of any serious and unexpected adverse events. 
 
17.3 Subject Protection 
17.3.1 
Subject Privacy  
In order to maintain patient confidentiality, all case report forms, study reports and 
communications relating to the study will identify subjects by initials and assigned subject 
numbers; subjects should not be identified by name. In accordance with local, national or 
federal regulations, the Investigator will allow the Sponsor or their designee personnel access 


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to all pertinent medical records in order to verify the data gathered on the case report forms 
and to audit the data collection process. Regulatory agencies such as the US Food and Drug 
Administration (FDA) may also request access to all study records, including source 
documentation for inspection. No material bearing a patient’s name will be kept on file by 
the Sponsor and patients will be informed of their rights within the ICF.  
17.3.2 
Rationale for Subject Selection 
The selection of subjects for this protocol will not be based on sex, race, or ethnic 
background. 
 
17.3.3 
Participation of Children 
Children will not be enrolled in this study. 
 
 
18. 
TRIAL ADMINISTRATIVE INFORMATION 
18.1 Protocol Amendments 
As the trial progresses, any amendments to the study protocol deemed necessary will be 
communicated to the Investigator by Celsion or its designee. All protocol amendments will 
undergo the same review and approval process as the original protocol. A protocol 
amendment may be implemented after it has been approved by the IRB/REB/IEC, unless 
immediate implementation of the change is necessary for subject safety. In that case, the 
situation must be documented and reported to the IRB/REB/IEC within 5 working days. 
 


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19. 
REFERENCES 
 
1. 
Benjamin RS, Wiernik PH, Bachur NR. Adriamycin chemotherapy-efficacy, safety, 
and pharmacologic basis of an intermittent single high-dosage schedule. Cancer. 
1974;33(1):19-27. 
2. 
Berber E, Pelley R, Siperstein AE. Predictors of survival after radiofrequency thermal 
ablation of colorectal cancer metastases to the liver: a prospective study. J Clin 
Oncol. 2005(a);23(7):1358-64.. 
3. 
Berber E, Rogers S, Siperstein A. Predictors of survival after laparoscopic 
radiofrequency thermal ablation of hepatocellular cancer: a prospective study. Surg 
Endosc. 2005(b);19(5):710-4. 
4. 
Berber, E., et al., “Laparoscopic radiofrequency ablation of hepatic tumors” (2004) 
Surgical Endoscopy 18: 390 – 396. 
5. 
Berber E, Siperstein AE. Perioperative outcome after laparoscopic radiofrequency 
ablation of liver tumors: an analysis of 521 cases. Surg Endosc. 2007;21(4):613-8. 
6. 
Bruix J, Sherman M. AASLD practice guideline. Management of hepatocellular 
carcinoma: an update. Hepatology. 2011;53(3):1020-2. 
7. 
Buscarini L, Rossi S, Fornari F, Di Stasi M, Buscarini E. Laparoscopic ablation of 
liver 
adenoma 
by 
radiofrequency 
electrocauthery. 
Gastrointest 
Endosc. 
1995;41(1):68-70. 
8. 
Chen MH, Wei Y, Yan K, Gao W, Dai Y, Huo L, et al. Treatment of strategy to 
optimize radiofrequency ablation for liver malignancies. J Vasc Interv Radiol. 
2006;17(4):671-83. 
9. 
Chen MS, Li JQ, Zheng Y, Guo RP, Liang HH, Zhang YQ, et al. A prospective 
randomized trial comparing percutaneous local ablative therapy and partial 
hepatectomy for small hepatocellular carcinoma. Ann Surg. 2006;243(3):321-8. 
10. Chen MH, Yang W, Yan K, Zou MW, Solbiati L, Liu JB, et al. Large liver tumors: 
protocol for radiofrequency ablation and its clinical application in 110 patients - 
mathematic model, overlapping mode, and electrode placement process. Radiology. 
2004;232(1):260-71.  
11. Curley SA. Radiofrequency ablation of malignant liver tumors. Oncologist 2001; 
6:14-23. 
12. Curley SA, Izzo F, Abdalla E, Vauthey JN. Surgical treatment of colorectal cancer 
metastasis. Cancer Metastasis Rev. 2004;23(1-2):165-82. 
13. Dodd GD 3rd, Frank MS, Aribandi M, Chopra S, Chintapalli KN. Radiofrequency 
thermal ablation: computer analysis of the size of the thermal injury created by 
overlapping ablations. AJR Am J Roentgenol. 2001;177(4):777-82. 
14. Dodd GD 3rd, Napier D, Schoolfield JD, Hubbard L. Percutaneous radiofrequency 
ablation of hepatic tumors: postablation syndrome. AJR Am J Roentgenol. 
2005;185(1):51-7. 


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15. Donelli MG, Zucchetti M, Munzone E, D'Incalci M, Crosignani A. Review: 
pharmacokinetics of anticancer agents in patients with impaired liver function. Eur J 
Cancer. 1998;34(1):33-46. 
16. Gasselhuber A, Dreher MR, Negussie A, Wood BJ, Rattay F, Haemmerich D. 
Mathematical spatio-temporal model of drug delivery from low temperature sensitive 
liposomes 
during 
radiofrequency 
tumour 
ablation. 
Int 
J 
Hyperthermia. 
2010;26(5):499-513. 
17. Goldberg SN, Kamel IR, Kruskal JB, Reynolds K, Monsky WL, Stuart KE, et al. 
Radiofrequency ablation of hepatic tumors: increased tumor destruction with adjuvant 
liposomal doxorubicin therapy. AJR Am J Roentgenol. 2002;179(1):93-101. 
18. Haemmerich D, Rossmann C. Radiofrequency ablation + ThermoDox computational 
modeling study. Final Report (2013). New Jersey: Celsion Corporation. Data on file. 
19. Johnson PJ, Alexopoulos A, Johnson RD, Williams R. Significance of serum 
bilirubin level in response of hepatocellular carcinoma to doxorubicin. J Hepatol. 
1986;3(2):149-53. 
20. Kim WR, Gores GJ, Benson JT, Therneau TM, Melton LJ 3rd. Mortality and hospital 
utilization for hepatocellular carcinoma in the United States. Gastroenterology. 
2005;129(2):486-93. 
21. Lin SM, Lin CJ, Lin CC, Hsu CW, Chen YC. Radiofrequency ablation improves 
prognosis compared with ethanol injection for hepatocellular carcinoma ≤ 4 cm. 
Gastroenterology. 2004;127(6):1714-23. 
22. Lin SM, Lin CJ, Lin CC, Hsu CW, Chen YC. Randomised controlled trial comparing 
percutaneous radiofrequency thermal ablation, percutaneous ethanol injection, an 
dpercutaneous acetic acid injection to treat hepatocellular carcinoma of 3 cm or less. 
Gut. 2005;54(8):1151-6. 
23. Llovet JM, Di Bisceglie AM, Bruix J, Kramer BS, Lencioni R, Zhu AX, et al. Design 
and endpoints of clinical trials in hepatocellular carcinoma. J Natl Cancer Inst. 
2008;100(10):698-711. 
24. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J 
Clin. 2005;55:74-108. 
25. Pfizer, Inc. Doxorubicin Hydrochloride for Injection, USP Prescribing Information 
Revised Jan. 2014 
26. Rhim H, Goldberg N, Dodd GD 3rd, Solbiati L, Lim HK, Tonolini M, et al. Essential 
techniques for successful radio-frequency thermal ablation of malignant hepatic 
tumors. Radiographics. 2001;21:S17-39. 
27. Rossi S, Di Stasi, Buscarini E, Cavanna L, Quaretti P, Squassante L, et al. 
Percutaneous RF interstitial thermal ablation in the treatment of small hepatocellular 
carcinoma. Cancer J Sci Am. 1995;1(1):73-81. 
28. Shiina S, Teratani T, Obi S, Sato S, Tateishi R, Fujishima T, et al. A randomized 
controlled trial of radiofrequency ablation with ethanol injection for small 
hepatocellular carcinoma. Gastroenterology. 2005;129(1):122-30. 


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29. Siperstein AE, Rogers SJ, Hansen PD, Gitomirsky A. Laparoscopic thermal ablation 
of hepatic neuroendocrine tumor metastases. Surgery. 1997;122(6):1147-54. 
30. Smith TJ, Khatcheressian J, Lyman GH, Ozer H, Armitage JO, Balducci L, et al. 
2006 update of recommendations for the use of white blood cell growth factors: an 
evidence-based clinical practice guideline. J Clin Oncol. 2006;24(19):3187-205. 
31. Swenson CE. A study of radiofrequency ablation + ThermoDox in the swine liver. 
Study CEL-1301 (2014). New Jersey: Celsion Corporation. Data on file. 
32. Tateishi R, Shiina S, Teratani T, Obi S, Sato S, Koike Y, et al. Percutaneous 
radiofrequency ablation for hepatocellular carcinoma. An analysis of 1000 cases. 
Cancer. 2005;103(6):1201-9. 
33. Thomas MB, Abbruzzese JL. Opportunities for targeted therapies in hepatocellular 
carcinoma. J Clin Oncol. 2005;23:8093-108. 
34. Uka K, Aikata H, Takaki S, Shirakawa H, Jeong SC, Yamashina K, et al. Clinical 
features and prognosis of patients with extrahepatic metastases from hepatocellular 
carcinoma. World J Gastroenterol. 2007;13(3): 414-20. 
35. Wood BJ, Poon RT, Locklin JK, Dreher MR, Ng K, Eugeni M, et al. Phase I study of 
heat-deployed liposomal doxorubicin during radiofrequency ablation for hepatic 
malignancies. J Vasc Interv Radiol. 2012;23(2):248-55. 
36. Yang Y, Nagano H, Ota H, Morimoto O, Nakamura M, Wada H, et al. Patterns and 
clinicopathologic features of extrahepatic recurrence of hepatocellular carcinoma 
after curative resection. Surgery. 2007;141(2):196-202. 
 
 
 
 
 


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20. 
APPENDICES 
20.1 
Appendix I: Child-Pugh Classification of Hepatic Impairment 
 
 
Encephalopathy* 
Ascites 
Bilirubin 
(mg/dL)  
Albumin 
(g/dL)  
INR 
Score 
 
 
 
 
 
1 
Absent 
Absent 
< 2 
> 3.5 
< 1.3 
2 
I / II 
Mild / moderate  
2 - 3 
2.8 - 3.5 
1.3 - 1.5 
3 
III / IV 
Severe 
> 3 
< 2.8 
> 1.5 
* Encephalopathy grades: 
Grade 0: normal consciousness personality, neurological exam and electroencephalogram 
Grade 1: restless, sleep disturbed, irritable/agitated, impaired handwriting, 5 cps waves 
Grade 2: lethargic, time-disoriented, inappropriate, asterixis, ataxia, slow triphasic waves 
Grade 3: somnolent, stuporous, place-disoriented, hyperactive reflexes, rigidity, slower waves 
Grade 4: unrousable coma, no personality/behavior, decerebrate, slow 2-3 cps activity 
 
Interpretation: 
Child Class A: 5 to 6 points  
Child Class B: 7 to 9 points  
Child Class C: 10 to 15 points  
 
Source: 
Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal 
hypertension. 
Edited 
by 
CG 
Child. 
Philadelphia: 
Saunders. 
1964:50-64. 
 
Pugh RNH, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the 
esophagus in bleeding oesophageal varices. Br J Surg. 1973;60:648-52. 
 
 
 
 
 


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20.2 
Appendix II: New York Heart Association (NYHA) Functional 
Classification for Heart Failure 
 
A functional and therapeutic classification for prescription of physical activity for cardiac 
patients.  
Class I: patients with no limitation of activities; they suffer no symptoms from ordinary 
activities.  
Class II: patients with slight, mild limitation of activity; they are comfortable with rest or 
with mild exertion.  
Class III: patients with marked limitation of activity; they are comfortable only at rest.  
Class IV: patients who should be at complete rest, confined to bed or chair; any physical 
activity brings on discomfort and symptoms occur at rest.  
 


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20.3 Appendix III: Prohibited Medications 
 
The active ingredient compound of ThermoDox (Doxorubicin) is a substrate (major) of 
CYP2D6, 3A4. Inducers and inhibitors of CYP3A4 may alter the metabolism of ThermoDox. 
The following CYP3A4 inducers and inhibitors are prohibited from screening through after 
study treatment.  Additionally, medications that could change the pharmacokinetic profile of 
ThermoDox or modify gastric pH are prohibited. Future updates to the list will be provided 
to the site as new information becomes available. 
 


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Drug Class 
Agent 
Wash-out1 
CYP3A4 Inducers 
Antibiotics 
all rifamycin class agents (e.g., rifampicin, 
rifabutin, rifapentine) 
14 days 
Anticonvulsants 
phenytoin, carbamazepine, barbiturates (e.g., 
phenobarbital) 
Antiretrovirals 
efavirenz, nevirapine 
Glucocorticoids (oral) 
cortisone (> 50 mg), hydrocortisone (> 40 mg),  
prednisone (> 10 mg), methylprednisolone (> 8 
mg), dexamethasone (> 1.5 mg, except the oral 
premedication which is part of the protocol)2 
 
Other 
St. John’s Wort, modafinil 
 
CYP3A4 Inhibitors 
Antibiotics 
clarithromycin, erythromycin, troleandomycin 
7 days 
Antifungals 
itraconazole, ketoconazole, fluconazole (> 150 mg 
daily), voriconazole 
Antiretrovirals, Protease 
Inhibitors 
delaviridine, nelfinavir, amprenavir, ritonavir, 
indinavir, saquinavir, lopinivir 
Calcium channel blockers 
verapamil, diltiazem 
Antidepressants 
nefazodone, fluvoxamine 
GI Agents 
cimetidine, aprepitant 
Other 
grapefruit, grapefruit juice 
amiodarone  
6 months 
Miscellaneous 
Antacids3 
Mylanta, Maalox, Tums, Rennies 
1 hour before and 
after dosing 
Herbal or dietary 
supplements 
Ginkgo biloba, kava, grape seed, valerian, ginseng, 
echinacea, evening primrose oil 
14 days 
Intravenous fat emulsions4 
 
1 day before and 
after dosing 
Lipid complexed drugs 
Fentanyl,  
1 day before and 
after dosing 
Liposomal drugs 
Abelect™, Ambisome™, Nyotran™ 
1 day before and 
after dosing 
 
1. At the time of screening, if a subject is receiving any of the above listed medications/substances, the 
medication or substance must be discontinued (if clinically appropriate) for the period of time 
specified prior to administration of the first dose of study drug treatment and throughout the period 
discussed above in order for the subject to be eligible to participate in the study. 
2. Glucocorticoid daily doses (oral)  1.5 mg dexamethasone (or equivalent) are allowed.  
Glucocorticoid conversions are provided in parentheses. 
3. Antacids may have an impact on absorption of oral premedication dexamethasone due to a change 
in stomach pH. 
4. Intravenous fat emulsions, with the exception of Propofol, are prohibited. 
 
 
 


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20.4 
Appendix IV: RFA Treatment Procedure 
 
Treating Physician Qualifications 
• Must have performed radiofrequency ablation therapy on hepatic tumors in at least 15 
patients. 
• Must have used RFA device that will be used in protocol to treat hepatic tumors in at 
least 5 patients. 
Ablation Equipment  
Only FDA-approved RFA equipment marketed by Covidien, Boston Scientific Corp., and 
Angiodynamics (RITA) will be used in the protocol; however, each doctor (Principal 
Investigator or sub-Investigator) performing RFA will be limited to the use of a single 
manufacturer’s device for all treatments for an individual patient.  
• Covidien RFA Equipment 
Monopolar RF ablation generator with automated ablation algorithm (using the 
current model, which may be replaced with more current models during the 
course of the study.) 
Cool-Tip RF ablation needles. 
Covidien generator Switch Box.  
Dispersive Electrodes. 
• Boston Scientific Corp. RFA Equipment 
Radiofrequency Generator (using the current model, which may be replaced with 
more current models during the course of the study.) 
LeVeen Needle Electrodes. 
Dispersive Electrodes. 
• Angiodynamics (RITA) RFA Equipment 
Radiofrequency Generator (using the current model, which may be replaced with 
more current models during the course of the study). 
StarBurst Electrodes.  
Dispersive Electrodes. 
 
Ablation Strategy for Individual Tumors  
The following are the minimum requirements for ablating tumors of a given size. At least 
4 ablation cycles lasting a total of ≥ 45 minutes should be performed. Since all tumors are 
not perfect spheres, the operator should use the maximum diameter to choose the 
appropriate ablation strategy. All tumors should be treated with the goal of ablating the 
tumor as well as a 360o 1.0 cm tumor free margin around each tumor. Updated 
operational manuals for each RFA device, detailing the specifics of electrode vs. tumor 
size, should be followed accordingly. 
 


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20.5 
Appendix V: Adverse Events (AEs) and Criteria for Determining 
Relationship of AE to Treatment 
 
Criteria for Determining Category of Relationship of Clinical Adverse Events to 
Treatment 
 
1 
 
Not related 
 
This category applies to those adverse events, which, after careful 
consideration, are clearly and incontrovertibly due to extraneous causes 
(disease, environment, etc.). 
2 
Unlikely 
(must have 
two) 
In general, this category can be considered applicable to those adverse 
events, which, after careful medical consideration at the time they are 
evaluated, are judged to be unrelated to the test drug or/and procedure.  
An adverse event may be considered unlikely if or when: 
 
 
1. 
 
2. 
 
3. 
4. 
It does not follow a reasonable temporal sequence from administration 
of the test drug or/and procedure. 
It could readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered 
to the subject. 
It does not follow a known pattern of response to the drug/procedure. 
It does not reappear or worsen when the drug/procedure is re-
administered. 
3 
Possibly 
(must have 
two) 
This category applies to those adverse events for which, after careful 
medical consideration at the time they are evaluated, a connection with 
the test drug or/and procedure administration appears unlikely but 
cannot be ruled out with certainty.  An adverse event may be 
considered possibly related if or when: 
 
 
1. 
 
2. 
 
3. 
It follows a reasonable temporal sequence from administration of the 
test drug/procedure. 
It could not readily have been produced by the subject’s clinical state, 
environmental or toxic factors, or other modes of therapy administered 
to the subject. 
It follows a known pattern of response to the test drug/procedure. 
 
4 
 
Probably 
(must have 
three) 
 
This category applies to those adverse events for which, after careful 
medical consideration at the time they are evaluated, are felt with a 
high degree of certainty to be related to the test drug or/and procedure.  
An adverse event may be considered probably related if or when: 


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1. 
 
2. 
 
 
3. 
 
 
4. 
It follows a reasonable temporal sequence from administration of the 
test drug/procedure. 
It could not be reasonably explained by the known characteristics of 
the subject’s clinical state, environmental or toxic factors or other 
modes of therapy administered to the subject. 
It disappears or decreases on cessation or reduction in dose.   
There are important exceptions when an adverse event does not 
disappear upon discontinuation of the drug, yet drug-relatedness  
clearly exists (e.g., bone marrow depression, fixed drug eruptions, 
tardive dyskinesia).  
It follows a known pattern of response to the test drug/procedure. 
5 
Definitely 
(must have 
all) 
This category applies to those adverse events that the Investigator feels 
are incontrovertibly related to test drug or/and procedure.  An adverse 
event may be assigned an attribution of definitely related if or when: 
 
 
1. 
 
2. 
 
 
3. 
 
 
 
4. 
It follows a reasonable temporal sequence from administration of the 
test drug/procedure. 
It could not be reasonably explained by the known characteristics of 
the subject’s clinical state, environmental or toxic factors or other 
modes of therapy administered to the subject. 
It disappears or decreases on cessation or reduction in dose with re-
exposure to drug.  (Note: This is not to be construed as requiring 
re-exposure of the subject; however, a category of definitely related 
can only be used when a recurrence is observed.)  
 
It follows a known pattern of response to the test drug/procedure. 
 
The Investigators are to record the Outcome to Date using the following four categories: 
Outcome 
Code 
Descriptor 
Definition 
1 
Recovered 
The patient fully recovered from the adverse event with 
no residual effect observable. 
2 
Adverse Event 
Still Present 
The adverse event itself is still present and observable. 
3 
Adverse Event 
Resolved 
The adverse event resolved, but residual effect(s) are 
still present and observable.   
4 
Death 
Death 
5 
Unknown 
The outcome of the adverse event could not be 
determined. 
 


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20.6 Appendix VI:  ECOG Performance Status 
 
Grade 
Functional Status 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work 
activities. Up and about more than 50% of waking hours 
3 
Capable of only limited self-care. Confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or 
chair 
5 
Dead 
 
ECOG = Eastern Cooperative Oncology Group, Robert Comis MD, Group Chair. 
 
Source:  Oken MM, Creech R, Tormey DC, et al. Toxicity and response criteria of the 
Eastern Cooperative Oncology Group. Am J Clin Oncol 1982;5:649-655. 
 
 
 
 
 
 
 
 
 
 
 
 
 


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20.7 Appendix VII: Requirements of Written Informed Consent 
Document (21 CFR 50.20 and 50.25 and ICH GCP, Topic E6, 
Section 4.8) 
 
Basic Elements of Informed Consent: 
In seeking informed consent, the following information shall be provided to each subject: 
• A statement that the study involves research, an explanation of the purpose of the 
research and the expected duration of the subject’s participation, a description of the 
procedures to be followed, and identification of any procedures that are 
experimental. 
• A description of any reasonably foreseeable risks or discomforts to the subject. 
• A description of any benefits to the subject or to others that may reasonably be 
expected from the research. 
• A disclosure of appropriate alternative procedures or courses of treatment, if any, 
which might be advantageous to the subject. 
• A statement describing the extent, if any, to which confidentiality of records 
identifying the subject will be maintained and that notes the possibility that the Food 
and Drug Administration or other regulatory agency may inspect the records. 
For research involving more than minimal risk, an explanation as to whether any 
compensation and an explanation as to whether any medical treatments are available if injury 
occurs and, if so, what they consist of, or where further information may be obtained. 
An explanation of whom to contact for answers to pertinent questions about the research and 
research subject’s rights, and whom to contact in the event of a research-related injury to the 
subject. 
A statement that participation is voluntary, that refusal to participate will involve no penalty 
or loss of benefits to which the subject is otherwise entitled, and that the subject may 
discontinue participation at any time without penalty or loss of benefits to which the subject 
is otherwise entitled. 
Additional Elements of Informed Consent: 
When appropriate, one or more of the following elements of information shall also be 
provided to the subject: 
• A statement that the particular treatment or procedure may involve risks to the 
subject (or to the embryo or fetus, if the subject is or may become pregnant), which 
are currently unforeseeable. 
• Anticipated circumstances under which the subject's participation may be terminated 
by the Investigator without regard to the subject’s consent. 
• Any additional costs to the subject that may result from participation in the research. 


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• The consequences of a subject's decision to withdraw from the research and 
procedures for orderly termination of participation by the subject. 
• A statement that significant new findings developed during the course of the research 
which may relate to the subject's willingness to continue participation will be 
provided to the subject. 
• The approximate number of subjects involved in the study. 
 
 
 


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20.8   Appendix VIII: AASLD Diagnostic Criteria 
 
This section summarizes diagnostic procedures from the American Association for the Study 
of Liver Diseases’ 2010 update to its practice guidelines (Bruix and Sherman 2011). 
 
HCC can be diagnosed radiologically, without the need for biopsy if the typical imaging 
features are present. This requires a contrast-enhanced study (dynamic CT-scan or MR). In 
the arterial phase, HCC enhances more intensely than the surrounding liver. In the venous 
phase, the HCC enhances less than the surrounding liver. 
  
Thus, to properly document the existence of HCC, a 4-phase study is required: unenhanced, 
arterial, venous and delayed phases. 
  
For lesions above 1 cm in diameter, either dynamic MRI or multidetector CT scanner should 
be used.  If the appearances are typical for HCC on either MRI or CT scan, as described 
above, then no further investigation is required and the diagnosis of HCC is confirmed.  If the 
appearances are not typical for HCC (and do not suggest hemangioma), then one of two 
strategies is possible. A second study (the other of CT scan or MRI) could be performed. If 
the appearances are typical, the diagnosis is confirmed. Alternatively, an atypical study could 
trigger a biopsy. 


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20.9   Appendix IX: Link to the most recent version of NCI Common 
Toxicity Criteria for Adverse Events (CTCAE), Version 4 
 
 
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf 
 


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20.10 Appendix X: Description of Amendment Changes 
Protocol Version 1.0 13-January-2014 to Version 2.0, 14-March-2014 
 
Sect 
Description/Rationale 
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Cover 
Protocol Version Date  
Version 2.0, 14-Mar-2014 
Version 1.0, 13-Jan-2014 
Cover 
The EudraCT Number was issued 
for this trial 
2014-000934-53 
2008-000963-41 
Synopsis, Section (S) 
3.3  ThermoDox, 
S8.1, S15.3.2.2 
FDA requested stratification by 
RFA route.   
Randomization and analysis will be 
stratified by maximum lesion diameter (3-
5 cm versus > 5-7 cm) and RFA route 
(laparoscopic, open surgical, 
percutaneous). 
Randomization and analysis will be 
stratified by maximum lesion diameter 
(3-5 cm versus > 5-7 cm) 
Synopsis, 5.1 
Standardized monitoring interval 
for PFS to ensure consistency 
across sites 
Following study treatment, subjects will 
undergo CT or MRI imaging scans  at 
months 1, 5, 9, 13, 17, 21, and 25 (+/- 2 
weeks), then at 6-month intervals (+/- 2 
weeks) until radiological progression is 
seen.. 
Following study treatment, subjects 
will undergo CT or MRI imaging 
scans consistent with local standard of 
care at each institution at an interval 
not > 6 months from the prior scan 
until radiological progression is seen. 


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Synopsis, 6.2.3 
Inclusion 
criteria 
update 
to 
characterize RFA eligibility and 
removed term. In additional all 
investigators 
that 
are 
RFA 
operators will complete formal 
training with an accompanying 
RFA training manual developed by 
the Sponsor. 
Overall health of livers since this is 
repetitive to the Child-Pugh Score 
inclusion criteria. 
• The position and accessibility of the 
target lesion allows for the safe 
administration 
of 
multiple 
ablation 
cycles or deployments to achieve a 
probe dwell time of > 45 minutes. 
• DELETED “Overall health of the liver 
 
• Procedure is expected to require 
multiple burn cycles or deployments 
to achieve an RFA probe dwell time 
≥ 45 minutes. 
• Overall health of the liver. 
 
Synopsis:  Exclusion 
Criteria 
Amended to be consistent with the 
clinical program development to 
date  
 
Platelet count < 75,000/mm3 
Platelet count < 60,000/mm3 
Synopsis;  
5.1: 8.3 
Added 
term 
“Only” 
for 
clarification 
Only FDA approved RFA devices are 
permitted for this trial. 
FDA approved RFA devices are 
permitted for this trial 


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Sect 
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Synopsis 
Updated this section of the 
synopsis to be consistent with 
section 8.4 
A standardized Radiofrequency Ablation 
sRFA treatment for this protocol is 
defined as the dwell time of ≥ 45 minutes 
measured from the first activation of the 
RFA probe to produce coagulative 
necrosis of target tissue through removal 
of the RFA probe after the final ablation 
cycle or deployment. This includes the 
multiple ablation cycles and repositioning 
time between cycles for an individual 
patient. An ablation cycle for this 
protocol is defined as the single activation 
of the probe or electrode in order to 
achieve a local coagulation necrosis in 
target tissue. The cycle may be completed 
by achieving a target temperature in the 
tissue or a target impedance. 
A 
standardized 
Radiofrequency 
Ablation (s)RFA treatment is defined 
as the dwell time of ≥ 45 minutes 
measured from the first activation of 
the RFA probe to ablate tissue 
through turning off the RFA generator 
after the final ablation cycle. This 
includes the multiple ablation cycles 
and repositioning time between cycles 
for an individual patient. 
 
PROTOCOL 
SYNOPSISSynopsis, 
S4.2.1, S15.3.2.4 
AE reporting requirement update to 
confirm events possibly, probably 
or definitely related to study 
treatment will be recorded at any 
point during the trial 
 
AEs which are assessed as possibly, 
probably, or definitely related to study 
treatment will be recorded at any point 
during the trial and must be followed until 
resolution or until the patient is clinically 
stable. 
AEs which are assessed as possibly, 
probably, or definitely related to study 
treatment will be followed until 
resolution or until the patient is 
clinically stable. 


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3.2 
Clarification to note RFA for lesion 
>5 cm and < 7 cm may be outside 
standard treatment in some regions. 
The 
sRFA/ThermoDox 
combination is being investigated 
as a curative treatment rather than 
as a palliative treatment. Some 
centers 
may 
not 
enroll 
this 
population. The risks included in 
the consent form. 
In the United States, palliative treatments 
such 
as 
transcatheter 
arterial 
chemoembolization (TACE) and sorafenib 
maybe standard treatment options for HCC 
tumors > 5 cm. However, in this study the 
combination of RFA and ThermoDox is 
being investigated as a curative treatment 
for patients with tumors > 5 cm to < 7 cm 
rather than for their palliation.  
 
 
 
New text.   
S4.2.1, S12.4.1 
PFS definitions clarified for 
consistency 
PFS will be measured from the date of 
randomization to the first date on which 
one of the following occurs:  
 
• 
Death of any cause  
• 
Treatment failure (inability to 
achieve CR after two RFA ± 
ThermoDox treatment sessions)  
• 
Progression due to local tumor 
recurrence after initial CR  
• 
Progression 
due 
to 
distant 
intrahepatic tumor recurrence  
• 
Progression due to extrahepatic 
tumor recurrence  
 
 
PFS will be measured from the date of 
randomization to the first date on 
which one of the following occurs:  
As determined by CT or MRI Scan 
An incomplete ablation following two 
RFA procedures 
Local recurrence of HCC tumor after 
complete initial ablation 
Any new distant intrahepatic HCC 
tumor 
Any new extrahepatic tumor 
Death from any cause 
 


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S6.2.4 
Added text for explaining potential 
risks. 
Doxorubicin HCl, the active agent in 
ThermoDox, 
is 
routinely 
given 
in 
chemotherapy 
regimens 
for 
multiple 
cycles after appropriate recovery intervals, 
usually at least 3 weeks. In contrast, the 
vast majority (84.8%; 291/343) of subjects 
in the RFA plus ThermoDox arm in the 
prior trial received only a single dose of 
ThermoDox. 
 
Doxorubicin HCl, the active agent in 
ThermoDox, is routinely given in 
chemotherapy regimens for multiple 
cycles after appropriate recovery 
intervals, usually at least 3 weeks.  
S6.2.4 
Added text for explaining potential 
risks for patients with elevated 
bilirubin levels at baseline and to 
describe plan to mitigating risk 
during the trial 
In the prior study, subjects with baseline 
serum bilirubin > 2.0 mg/dL had a higher 
incidence 
subsequent 
grade 
3+ 
hyperbilirubinemia and of grade 3+ 
hepatic failure. However, the greater 
incidence of hepatic failure consisted of a 
single patient with grade 3 liver failure. 
Among patients with an elevated bilirubin 
level at baseline, there were no subsequent 
serious 
hepatobiliary 
adverse 
events 
except 
for 
2 
cases 
of 
hyperbilirubinemia/blood 
bilirubin 
increased. The DMC is responsible for 
unblinded monitoring of subjects with 
elevated (> 2.0 mg/dL and < 3.0 mg/dL) 
serum bilirubin levels and will advise if 
any dose or protocol modification is 
needed to mitigate risk to such patients.  
New text. 


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S6.2.4 
Include potential for increased risk 
to patients if a biopsy has not 
confirmed HCC. 
AASLD treatment guidelines permit the 
diagnosis with the use of imaging 
modality 
only 
without 
a 
biopsy 
histological or cytological confirmation of 
the specimen. Procurement of a biopsy 
increases risk to subjects with liver disease 
and therefore is not always indicated. 
However patients who undergo an RFA 
treatment without a biopsy may be at 
increased 
risk 
for 
undergoing 
an 
unnecessary ablation or be at risk for 
seeding 
for 
subcapsular 
or 
poorly 
differentiated disease. This risk is minimal 
and accepted within clinical practice 
guidelines. 
 
New Text 


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S6.2.4 
Include potential increased risk for 
subjects whose lesions are > 5 cm. 
RFA has been used safely in tumors up to 
7 cm (Chen, et al. 2004; Curley, et al. 
2004; Dodd, et al. 2001; Tateishi, et al. 
2005).  In the United States and other local 
regions, palliative treatments such as 
transcatheter arterial chemoembolization 
(TACE) and sorafenib are the standard of 
care for HCC tumors > 5 cm. However, in 
this study the combination of RFA and 
ThermoDox is being investigated as a 
curative treatment for patients with tumors 
> 5 cm to < 7 cm rather than for their 
palliation. There is risk that RFA is not as 
effective in the larger tumors, however this 
has not been established. Subjects would 
be eligible to receive palliative therapy as 
medically indicated after progression is 
observed 
New Text 
S 7.2 
Study Discontinuation- New text to 
clarify subjects may select to 
continue in OS. Site personnel 
should discusswith subject. 
If a subject discontinues from retreatments 
or from the PFS imaging interval, the 
patient should still be contacted for overall 
survival until withdraw consent for study 
participation. 
New text 


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S7.3 
Study non-compliance- New text to 
clarify subjects may continue in 
OS. Site personnel should discuss 
with subject. 
If a subject is discontinued from the study 
due to noncompliance of follow up visits, 
the patient should still be contacted for 
overall survival until end of study or 
withdraw consent from study participation. 
 
New text 
S8.5.4 
Guidance to investigator for non-
hematologic toxicities >grade 3 
prior to a retreatment 
Among patients requiring re-treatment 
after incomplete initial ablation who have 
developed a non-hematologic toxicity ≥ 
grade 3, no dose modification is required. 
Instead, such subjects will not be re-
treated until the severity of the non-
hematologic toxicity drops to < grade 2. 
 
New text.   
S10.1.4, 
S10.1.5, S10.1.8 
Standardized 4 month safety 
interval surveillance to include PE, 
Vitals, ECGs. 
• Month 5, Month 9, Month 13 (+/- 2 
weeks) 
or 
disease 
progression, 
whichever occurs first 
 
 
Patients 
who 
receive 
study 
retreatment will have an additional 
physical exam at Month 3 following 
each retreatment. 
 


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S10.1.7 
Standardized 4 month PFS 
secondary endpoint monitoring 
CT or MRI scans (Chest, Abdomen, and 
Pelvis) will be done within 21 days prior 
to study treatment to confirm the presence 
of an evaluable lesion and at Day 28 to 
assess whether a complete initial ablation 
was achieved. Additional imaging will be 
done at months, 5, 9, 13, 17, 21, 25, then 
every 6 months (+/- 2 weeks) until disease 
progression 
is 
seen. 
The 
following 
requirements apply to imaging for this 
study: 
• 
The same modality and technique 
must be used for all scans of an 
individual patient. 
 
CT or MRI scans will be done within 
21 days prior to study treatment to 
confirm the presence of an evaluable 
lesion and at Day 28 to assess whether 
a 
complete 
initial 
ablation 
was 
achieved. Imaging procedures, follow-
up intervals, and the determination of 
progression will be done according to 
the local standard of care with the 
following exceptions: 
• 
The 
same 
modality 
and 
technique must be used for all 
scans of an individual patient. 
• 
The 
follow 
up 
imaging 
interval 
cannot 
exceed 
6 
months.  
 
S10.1.9 
1 month adjustment for LVEF 
exam at 1 year and then language 
to advise when repeat scan is 
necessary. 
Follow-up scans must be completed on 
Day 28 (+/- 3 days) and at Month 13 or at 
time progression of disease, whichever 
occurs first. 
A decrease of >10% in resting LVEF that 
becomes 
abnormal 
(lower 
than 
the 
institutional lower limit of normal) should 
be further evaluated by repeat examination 
for subjects with a total cumulative 
doxorubicin of ≥ 300 mg/m2.  
 
Follow-up scans must be completed on 
Day 28 (+/- 3 days) and at Month 12 
or at time progression of disease, 
whichever occurs first.   


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S10.1.11 
Standardized long term safety 
surveillance for Liver Function 
Testing 
Additional post-treatment liver function 
tests (Chemistry and PT/INR), will be 
collected at months 5, 9, 13, 17, 21 and 25 
(+/- 2 weeks) or disease progression, 
whichever occurs first. 
Post-treatment liver function tests 
(Chemistry and PT/INR), will be 
collected at intervals not to exceed 6 
months 
following 
study 
drug 
administration through Month 12. 
S10.2 
Clarification 
to 
simplify 
understanding. 
The second ablation must occur no later 
than 21 days after the first post-ablation 
scan assessment at Day 28. 
The second ablation must occur  no 
earlier than 21 days after the initial 
ablation and no later than 21 days after 
the first post-ablation scan assessment 
at Day 28. 
 
S10.3 
Imaging 
intervals 
and 
liver 
function 
test 
intervals 
are 
standardized 
elsewhere 
in 
the 
protocol 
No replacement language 
Radiological Imaging interval and 
Liver Function Test can be scheduled 
according to local standard treatment 
guidelines at intervals not to exceed 6 
months. The radiological imaging will 
continue until Investigator determined 
radiological progression. The Liver 
Function Tests are to be monitored 
through Month 12 following last study 
drug infusion. 
 


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S12.1 
Assessment of efficacy definitions 
were added to the protocol to 
ensure consistency across sites 
All patients will be monitored for survival 
by recording their visits during routine 
follow up for response to treatment.  The 
visits are scheduled to occur every four 
months from the first imaging study 
confirming complete ablation until month 
25 or radiological progression, whichever 
comes first.   If patients have not 
demonstrated radiological progression at 
month 25 then the imaging visit schedule 
is reduced to every six months until 
progression.   Survival is confirmed at 
every imaging visit. 
Once 
radiological 
progression 
is 
confirmed then follow up for survival is 
required.  Sites are required to confirm 
contact with the subject during either a 
clinic visit or a telephone contact every 
three months.  It is expected that subject 
follow up will be about five years.  
 
Additional language.   


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S12.2 
Secondary Endpoint progression 
free survival includes mRESIST 
details to ensure consistency during 
standardized interval training. 
The 
protocol 
incorporates 
modified 
RECIST (mRECIST) developed for HCC 
clinical research as a basis to evaluate 
tumor response.  The mRECIST enables 
assessment of overall response by taking 
into account target lesion response, and 
presence or absence of new lesions.  A 
separate imaging manual and imaging 
training program has been developed for 
this study in order to ensure uniformity in 
imaging technique and imaging review in 
accordance with mRECIST.  
 
Additional language. 


Protocol No.: 104-13-302 
 
 
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Version 2.0, 14-March-2014 
 
Celsion Corporation 
 
Confidential 
 
Sect 
Description/Rationale 
Changed to 
Changed From 
S12.3 
Baseline Assessment definitions 
added for consistency 
The baseline assessment must include a 
comprehensive evaluation of the chest, 
abdomen and pelvis.  The HCC tumor 
identified on the eligibility scan should be 
defined as target lesion and its longest 
diameter should be measured on the 
contrast-enhanced 
CT 
or 
contrast-
enhanced MRI scan. This measurement 
should reflect the overall longest tumor 
diameter, regardless of the presence of 
internal areas of spontaneous necrosis. In 
the study protocol, intermediate size is 
defined as a tumor lesion larger than 3.0 
cm but not exceeding 7.0 cm in longest 
diameter. Since the study will recruit 
patients with solitary tumors and no 
evidence 
of 
vascular 
invasion 
or 
extrahepatic spread, the eligible size HCC 
lesion detected on the eligibility scan is 
expected to be the only target lesion. No 
additional target or non-target lesions 
should be detectable on the eligibility scan 
to allow enrollment in the study 
 
Additional language. 


Protocol No.: 104-13-302 
 
 
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Version 2.0, 14-March-2014 
 
Celsion Corporation 
 
Confidential 
 
Sect 
Description/Rationale 
Changed to 
Changed From 
S12.4 
Target lesion local response and 
local recurrence added for guidance 
to investigators in reporting PFS 
endpoint. 
The image acquisition protocols used for 
any post-baseline assessments should be 
consistent with the protocol used for the 
baseline eligibility scan. Baseline images 
for treatment eligibility will be confirmed 
centrally 
before 
RFA 
treatment.  
Investigator 
determined 
radiological 
confirmation of complete ablation will 
occur at one month post RFA.  If initial 
RFA is incomplete then a second, and 
final, attempt may be made for a complete 
ablation for subject to stay on protocol. 
Once a complete ablation is confirmed 
then patients are monitored radiologically 
until progression.  The imaging interval 
will be every four months until month 25 
then every six months thereafter.  No 
imaging 
studies 
are 
required 
once 
progression is confirmed.  
 
The disappearance of any intratumoral 
enhancement in the target tumor lesion 
after treatment with study treatment will 
be classified as complete response (CR), 
while the persistence of any areas of 
intratumoral enhancement consistent with 
residual viable tumor will be considered as 
incomplete response (IR). Failure to 
achieve 
a 
CR 
after 
two 
RFA 
± 
ThermoDox treatment sessions will be 
classified as treatment failure. Tumor 
recurrence detected within or around the 
target lesion after having achieved initial 
CR will be classified as local recurrence. 
Tumor recurrences will be defined as local 
if they are located 1 cm or less from the 
ablation margin 
Additional language. 


Protocol No.: 104-13-302 
 
 
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Sect 
Description/Rationale 
Changed to 
Changed From 
S12.4.1 
New definition of Equivocal 
response in newly created Table 
3 and addition of Table 2Table 4, 
Overall Responses for Possible 
combination 
of 
Tumor 
Responses.   
Equivocal (EQ) 
A new liver lesion that is smaller than 1 
cm in longest diameter OR fails to show a 
typical enhancement profile should be 
considered 
as 
equivocal 
and 
not 
conclusive for disease progression. Such 
lesions can be diagnosed as HCC by 
evidence 
of 
either 
a 
change 
in 
enhancement pattern OR at least 1-cm 
interval growth in subsequent scans. 
*Plus Table 4 titled Overall Responses for 
possible combination of tumor responses 
in the target lesion with or without the 
appearance 
of 
new 
intrahepatic 
or 
extrahepatic lesions. 
 
New text.   
S14 
Additional responsibilities for the 
DMC.   
A Data Monitoring Committee (DMC) 
will evaluate safety data on an ongoing 
basis at regular intervals during subject 
accrual and follow-up. The DMC is 
responsible for unblinded monitoring of 
subjects with elevated (> 2.0 mg/dL and < 
3.0 mg/dL) serum bilirubin levels and will 
advise if any dose or protocol modification 
is needed to mitigate risk to such patients. 
The Sponsor is responsible to report 
relevant 
SAEs 
to 
applicable 
local, 
national, and/or international regulatory 
body. 
A Data Monitoring Committee (DMC) 
will evaluate safety data on an ongoing 
basis at regular intervals during subject 
accrual and follow-up. The Sponsor is 
responsible to report relevant SAEs to 
applicable 
local, 
national, 
and/or 
international regulatory body.   


Protocol No.: 104-13-302 
 
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Version 2.0, 14-March-2014 
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Confidential 
 
 
END OF PROTOCOL 
 

SAP_001.pdf: 
STATISTICAL ANALYSIS PLAN 
Celsion Corporation 
104-13-302 
 
 
 
 
 
 
 
 
 
 
STATISTICAL ANALYSIS PLAN 
 
 
Celsion Corporation 
997 Lenox Drive, Suite 100 
Lawrenceville, NJ  08648 USA 
 
 
A Phase III, Randomized, Double Blind, Dummy-Controlled Study of 
ThermoDox® (Lyso-Thermosensitive Liposomal Doxorubicin-LTLD) in 
Hepatocellular Carcinoma (HCC) using standardized Radiofrequency 
Ablation (RFA) treatment time ≥ 45 minutes for solitary lesions ≥ 3 cm 
to ≤ 7 cm. 
 
Clinical Study Protocol No. 104-13-302 
NCT No. 02112656 
 
 
Prepared by 
XXXXXXXXXX 
inVentiv Health Clinical 
500 Atrium Dr. 
Somerset, NJ  08873   USA 
 
 
 
 
 
 
 
 
 
This document contains confidential information of Celsion Corporation.  Any viewing or 
disclosure of such information that is not authorized in writing by Celsion Corporation is strictly 
prohibited.  Such information may be used solely for the purpose of reviewing or performing this 
study. 
 
 
Version 3.0 Date:  16 June 2020 


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STATISTICAL ANALYSIS PLAN 
SIGNATURE PAGE 
 
 
 
Celsion Corporation 
997 Lenox Drive, Suite 100 
Lawrenceville, NJ  08648 USA 
 
 
A Phase III, Randomized, Double Blind, Dummy-Controlled Study of 
ThermoDox® (Lyso-Thermosensitive Liposomal Doxorubicin-LTLD) in 
Hepatocellular Carcinoma (HCC) using standardized Radiofrequency Ablation 
(RFA) treatment time ≥ 45 minutes for solitary lesions ≥ 3 cm to ≤ 7 cm. 
 
Clinical Study Protocol No. 104-13-302 
 
 
 
 
 
 
• 
• 
 
 
• 
• 
 
 
• 
• 
 
 
• 
• 
 
 
XXXXXXXXXX Syneos Health 
Approval Date 
XXXXXXXXXX Syneos Health 
Approval Date 
XXXXXXXXXX Celsion Corporation 
Approval Date 
XXXXXXXXXX Celsion Corporation 
Approval Date 


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STATISTICAL ANALYSIS PLAN 
REVISION HISTORY 
Version 
Version Date 
Author 
Description of Modification 
0.1 
27 March 2014 
XXXXXXXXXX 
First Draft based on protocol dated 
14 March 2014 
0.2 
13 May 2014 
XXXXXXXXXX 
Updated due to FDA comments 
1.0 
05 February 2016 
XXXXXXXXXX 
1. 
Updated footnote on the cover 
page from Version Date: 13 
May 2014 to Version Date: 02 
February 2016. 
2. 
Updated footnote in the body of 
the document from Draft 0.2 - 
13May2014 to Final 1.0 
02Feb2016. 
3. 
Updated Signature page with 
Elizabeth Zobre’s title and 
replaced Lori Davis with Daniel 
Strieter. 
4. 
Updated to be based on 
Amended Protocol Version 
2.1e, 04-August-2014: Section 
1.0 Introduction change from 
Protocol Appendix IV to 
Protocol Appendix 20.4 
1.1 
04 April 2019 
XXXXXXXXXX 
Updated An additional 72-hour 
CBC with differential is required 
for eligibility criteria from 
Version 2.0, 14-March-2014 to 
Version 2.1.e, 01-Aug-2014 
1.2 
22 May 2019 
XXXXXXXXXX 
Updated with amendments to 
tables, based on client comments 
2.0 
05 June 2019 
XXXXXXXXXX 
Included last comments and 
provided for approval 
3.0 
06 May 2020 
XXXXXXXXXX 
Revise erroneous wording for 
PFS censoring rule (section 3.0) 
and include detailed classification 
of Protocol Deviations in Section 
6.2.2 


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TABLE OF CONTENTS 
1. 
INTRODUCTION ............................................................................................................................ 6 
1.1 
Study Objectives .............................................................................................................................. 6 
1.2 
Study Design .................................................................................................................................... 6 
1.3 
Study Procedures and Timepoints .................................................................................................... 8 
2. 
STUDY POPULATIONS ................................................................................................................. 8 
3. 
DEFINITIONS AND DERIVED VARIABLES............................................................................... 8 
4. 
EFFICACY ENDPOINTS ................................................................................................................ 9 
5. 
SAFETY ENDPOINTS .................................................................................................................. 10 
6. 
STATISTICAL METHODOLOGY ............................................................................................... 10 
6.1 
Statistical and Analytical Issues ..................................................................................................... 10 
6.1.1 
Statistical Methods ............................................................................................................. 10 
6.1.2 
Handling of Dropouts and Missing Data ............................................................................ 11 
6.1.2.1 
Dropouts ........................................................................................................................ 11 
6.1.2.2 
Missing Data .................................................................................................................. 11 
6.1.3 
Pooling of Investigator Sites .............................................................................................. 11 
6.1.4 
Determination of Sample Size ........................................................................................... 11 
6.2 
Subject Disposition, Baseline and Treatment Characteristics ........................................................ 12 
6.2.1 
Subject Disposition ............................................................................................................ 12 
6.2.2 
Major Protocol Violations ................................................................................................. 12 
6.2.3 
Subject Baseline Characteristics ........................................................................................ 13 
6.2.4 
Treatment Exposure and Compliance ................................................................................ 13 
6.2.5 
Prior and Concomitant Medications and Therapies ........................................................... 13 
6.2.6 
Medical Histories ............................................................................................................... 13 
6.2.7 
Follow-up Period ............................................................................................................... 14 
6.3 
Efficacy Analysis ........................................................................................................................... 14 
6.3.1 
Primary Efficacy Variable(s) ............................................................................................. 14 
6.3.2 
OS Supportive Analyses .................................................................................................... 15 
6.3.3 
Secondary Efficacy Variable(s) ......................................................................................... 15 
6.4 
Safety Analysis .............................................................................................................................. 16 
6.4.1 
Treatment-Emergent Adverse Events ................................................................................ 16 
6.4.2 
Laboratory Parameters ....................................................................................................... 17 
6.4.3 
Physical Examination ......................................................................................................... 17 
6.4.4 
Vital Signs ......................................................................................................................... 17 
6.4.5 
12-Lead ECGs ................................................................................................................... 17 
6.4.6 
Echocardiograms/MUGA scans for LVEF monitoring ...................................................... 18 
6.5 
Data Monitoring Committee .......................................................................................................... 18 
6.6 
Interim Analysis ............................................................................................................................. 18 
7. 
TABLES, LISTINGS, AND FIGURES LAYOUT ......................................................................... 18 
8. 
LIST OF TABLES, LISTINGS AND FIGURES ........................................................................... 19 
9. 
REFERENCES ................................................................................................................................ 19 
10. 
APPENDICES ................................................................................................................................ 21 
10.1 
Standard Laboratory Ranges ...................................................................................................... 21 
10.2 
NCI CTCAE Laboratory Grades ............................................................................................... 22 


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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
Abbreviation 
Definition 
 
 
AASLD 
American Association for the Study of Liver Disease 
AE 
Adverse Event 
AT 
As-Treated 
CBC 
Complete Blood Count 
CI 
Confidence Interval 
CPH 
Cox Proportional Hazard 
CRF 
Case Report Form 
CR 
Complete Response 
CT 
Computerized Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
DMC 
Data Monitoring Committee 
ECG 
Electrocardiogram 
HCC 
Hepatocellular Carcinoma 
ITT 
Intent-to-treat 
LVEF 
Left Ventricular Ejection Fraction 
MedDRA 
Medical Dictionary for Regulatory Activities 
MRI 
Magnetic Resonance Imaging 
MUGA 
Multiple gated acquisition 
NCI 
National Cancer Institute 
OS 
Overall Survival 
PFS 
Progression-Free Survival 
PT/INR 
Prothrombin Time/International Normalized Ratio 
RFA 
Radiofrequency Ablation 
SAE 
Serious Adverse Event 
SOC 
System Organ Class 
sRFA 
Standardized Radiofrequency Ablation with treatment dwell time ≥45 min. 
TEAE 
Treatment-emergent adverse events 
WHO 
World Health Organization 


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1. 
INTRODUCTION 
 
Hepatocellular carcinoma (HCC) is the sixth most common neoplasm worldwide, but its very poor prognosis 
makes it the third leading cause of cancer-related mortality, responsible for about 600,000 deaths annually (Parkin, 
et al. 2005). In the US, 18,000 new cases of HCC are diagnosed each year and the incidence is steadily increasing, 
almost doubling since 1998. HCC is commonly diagnosed in patients with longstanding hepatic disease and 
cirrhosis (primarily due to hepatitis C in US and Europe and to hepatitis B in Asia). Mortality and hospitalization 
due to HCC, as well as hospital-related costs (inflation adjusted), increased approximately two-fold from 1988 to 
2000 (Kim et al. 2005, Thomas and Abbruzzese 2005). The incidence of extrahepatic metastases in patients with 
HCC is generally around 15%, which includes such metastases both at the initial diagnosis of HCC or during 
follow-up regardless of treatment (Uka, et al. 2007; Yang, et al. 2007). 
 
Surgical resection is the mainstay of curative treatment. However, no more than 30% of HCC patients are 
considered suitable for surgical treatment because of tumor size, multifocal tumors, vascular invasion, presence 
of extrahepatic metastases, and/or extensive liver impairment. Liver transplantation is an alternative curative 
treatment, but its application is limited by a severe shortage of liver graft donors (Llovet, et al. 2008). Thermal 
ablation modalities such as radiofrequency ablation (RFA), microwave ablation, and high-intensity focused 
ultrasound have emerged as important treatment options for such patients in recent years. 
 
For HCC tumors > 3 cm, overlapping ablations are required, and this overlapping can miss some micro metastases 
(Chen, et al. 2004; Curley, 2001; Dodd, et al. 2001; Chen, et al. 2006). If the efficacy of RFA for HCC tumors ≥ 
3.0 cm could be increased, as by an adjuvant, it would be a formidable curative modality. 
 
In this study, RFA treatments will be administered according to the RFA Treatment Procedure and device 
instructions (Protocol Appendix 20.4). Investigators at each site that meet the experience qualifications to perform 
RFA in this study will complete formal training with an accompanying RFA training manual developed by the 
Sponsor. All subjects will undergo an RFA treatment dwell time lasting ≥ 45 minutes. 
 
To sum up, the worldwide HCC population is large and growing. The vast majority, including all those with 
tumors ≥ 3 cm, are incurable. These patients have an unmet need for more effective therapies. 
 
1.1 
Study Objectives 
 
The primary objective is to compare overall survival (OS) between subjects receiving RFA plus ThermoDox 
versus RFA alone, using a standardized Radiofrequency Ablation (sRFA) treatment dwell time ≥ 45 minutes. 
 
The secondary objectives are to compare progression-free survival (PFS) and safety between subjects receiving 
sRFA plus ThermoDox versus sRFA alone, using a standardized treatment dwell time ≥ 45 minutes. 
 
1.2 
Study Design 
 
This is a 1:1 randomized, double blind, dummy controlled multicenter trial to evaluate the efficacy and safety 
of ThermoDox plus sRFA compared to sRFA alone using standardized treatment dwell time ≥ 45 min. for 
solitary HCC lesions ≥ 3.0 cm to ≤7.0 cm for 550 subjects at up to 100 study centers. 
 
An sRFA treatment for this protocol is defined as the dwell time of ≥ 45 minutes measured from the first 
activation of the RFA probe to produce coagulative necrosis of target tissue through removal of the RFA probe 


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after the final ablation cycle or deployment. This includes the multiple ablation cycles and repositioning time 
between cycles for an individual subject. 
 
Eligible HCC subjects will have a solitary lesion not amenable to curative resection consistent with clinical 
diagnosis of AASLD classification guidelines and will be candidates for RFA. Subjects will be randomly 
assigned to receive either standardized sRFA plus ThermoDox at 50 mg/m2 or standardized sRFA plus a 
dummy infusion using a standardized RFA dwell time ≥ 45 minutes. Randomization and analysis will be 
stratified by maximum lesion diameter (3-5 cm versus > 5-7 cm) and RFA route (laparoscopic, open surgical, 
percutaneous). 
 
Screening Period 
Subjects will be evaluated up to 21 days prior to the RFA procedure date to establish eligibility for study 
treatment. Subjects must meet all the study inclusion/exclusion criteria prior to randomization to a treatment 
arm. 
 
Treatment Period 
Subjects who meet the eligibility criteria will be randomly assigned to either sRFA plus ThermoDox or sRFA 
plus dummy infusion using a web-based randomization system. The RFA procedure day will be Day 0 and 
subjects will return to the clinic Day 14 and Day 28. Subjects with a complete ablation by imaging will 
continue in the follow up period described below. 
 
A subject who has an incomplete ablation is eligible for 1 retreatment procedure within 21 days after 
radiological imaging exam showing residual disease at Day 28. Subjects will be retreated only once with the 
same RFA equipment and treatment assigned at randomization. Baseline safety evaluations must meet the 
eligibility parameters prior to a retreatment. Subjects with a complete ablation after retreatment will be 
followed for both OS and PFS. If after 2 ablations the subject has local, distant intrahepatic, or extrahepatic 
HCC, then the subject will be considered a treatment failure and will have met the PFS endpoint. The subject is 
still followed for OS every 3 months after progression. 
 
Among subjects who are not treatment failures, up to five repeat treatments are permitted to treat a recurrent 
lesion or to treat newly identified local or distant intrahepatic lesions at the Investigator’s discretion after the 
PFS endpoint is reported and with agreement from the Sponsor. The subject must be eligible for retreatment 
consistent with the safety eligibility criteria and will be retreated with the same randomized treatment. 
 
Subjects who develop extrahepatic lesions will have met the PFS endpoint and are no longer eligible for further 
protocol treatment; they will be followed for OS. 
 
Follow up visits are performed Day 14 and Day 28 (+/- 3 days) following the treatment. Subjects with bilirubin 
levels > 2.0 mg/dL and ≤ 3.0 mg/dL will return to the clinic on Day 7 for additional safety assessments. 
Exclusion concomitant medications are to be restricted through Day 28 following study treatment. 
 
Follow-Up Period 
Following study treatment, subjects will undergo CT or MRI imaging scans (chest, abdomen, and pelvis)  at 
months 1, 5, 9, 13, 17, 21, and 25 (+/- 2 weeks), then at 6-month intervals (+/- 2 weeks) until radiological 
progression is seen. The same imaging modality and measurement of assessment should be used to characterize 
disease at baseline and during follow up for an individual subject. Investigator determined radiological 
progression must be observed and recorded prior to beginning alternate treatments for HCC. Post-progression 
treatments will be reported and the subject will continue to be followed for OS. 


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To provide surveillance for any late hematologic, cardiac, or liver toxicity, the following additional safety 
assessments will be done: 
• 
Physical examination, assessment of vital signs, ECGs, CBC with differential, serum chemistry, PT/INR 
and urinalysis at Month 5, Month 9, and Month 13 (+/- 2 weeks) or at disease progression, whichever 
occurs first. 
• 
LVEF monitoring at Month 13 or at disease progression, whichever occurs first. 
• 
Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 25 (+/- 2 weeks) or at disease 
progression, whichever occurs first. 
 
The site will contact all subjects every 3 months after radiological progression to document vital status until the 
subject expires or withdraws consent from the study. The follow-up contacts across all clinical sites may be 
coordinated using the same 3-month interval. 
 
1.3 
Study Procedures and Timepoints 
 
The study procedures and time points are described in Section 10 of the Protocol. 
 
 
 
2. 
STUDY POPULATIONS 
 
- 
Intent-to-Treat (ITT) population: This population includes all randomized subjects and is the primary 
population for subject characteristics and all efficacy parameters. All analyses using this population will 
be based on the treatment to which each subject was randomized. 
- 
As-Treated (AT) population: This population includes all subjects who actually received at least one 
application of RFA plus ThermoDox (TR) or RFA + dummy infusion (PR). This population will be used 
for the safety analyses. All analyses using this population will be based on the treatment actually received. 
 
 
 
3. 
DEFINITIONS AND DERIVED VARIABLES 
 
Age (years): integer [(Date of Informed Consent –Date of Birth +1)/365.25] 
 
Baseline results are those reported at the last visit on or before the Procedure Day 0 pre-dose visit. 
Study Day: Date in question – Date of Randomization 
Overall Survival is defined as the time (in months) from the date of randomization to the death date. In the absence 
of death confirmation or for subjects alive as of the OS cut-off date, survival time will be censored at the date of 
last study follow-up, or the cut-off date, whichever is earlier. 
 
Progression-free survival is defined as the time (in months) from the date of randomization until the date of the 
Investigator-assessed radiological disease progression (PD) or death due to any cause. In the absence of PD 
confirmation or for subjects without PD as of the cut-off date, survival time will be censored at the date of last 
tumor follow-up. 


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Censoring Rules for the Secondary Efficacy Parameter: PFS 
Description 
Outcome 
Date PD/Censored 
No baseline radiological assessments 
Censored 
Randomization 
Treatment failures (subjects with 
incomplete ablations after two RFA 
procedures) 
PD event 
Date of radiological assessment after 2nd RFA 
procedure that shows residual disease 
PD documented between scheduled visits 
PD event 
Date of earliest radiological assessment with 
evidence of PD 
PD documented after one missed 
scheduled visit 
PD event 
Date of earliest radiological assessment with 
evidence of PD 
Death before first radiological assessment 
PD event 
Date of death 
Death between adequate assessment visits 
PD event 
Date of death 
Death or PD after two or more missed 
scheduled visits 
Censored 
Date of latest radiological assessment prior to 
missing assessments 
Alive with no PD at the analysis cut-off 
date 
Censored 
Date of last radiological assessment 
Receive non-study cancer treatment 
before progression 
Censored 
Date of last radiological assessment before 
non-study cancer treatment initiated 
Liver transplant or liver resection before 
PD 
Censored 
Date of last tumor assessment for progression 
before the procedure 
Discontinues/Withdraws from study 
without progression; no other follow-up 
information 
Censored 
Date of last radiological assessment for 
progression before date of discontinuation 
 
Treatment-emergent adverse events (TEAEs) are defined as those adverse events which start or worsen on or 
after the first dose. 
 
 
 
4. 
EFFICACY ENDPOINTS 
 
Overall Survival is the primary efficacy endpoint of this study. All patients will be monitored for survival by 
recording their visits during routine follow up for response to treatment. The visits are scheduled to occur every 
four months from the first imaging study confirming complete ablation until month 25 or radiological 
progression, whichever comes first. If patients have not demonstrated radiological progression at month 25 then 
the imaging visit schedule is reduced to every six months until progression.  Survival is confirmed at every 
imaging visit. Once radiological progression is confirmed then follow up for overall survival will be confirmed 
every three months. It is expected that subject follow up will be about five years. 
 
Progression-free Survival is the secondary efficacy endpoint of this study. The protocol incorporates modified 
RECIST (mRECIST) developed for HCC clinical research as a basis to evaluate tumor response. CT or MRI 
scans (chest, abdomen, and pelvis) will be done at baseline and post-treatment at months 1 (Day 28), 5, 
9, 13, 17, 21, 25, then every 6 months until radiological progression is seen. 


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5. 
SAFETY ENDPOINTS 
 
- 
Adverse events 
- 
Laboratory assessments: hematology including CBC with differential, clinical chemistry, PT/INR, and 
urinalysis 
- 
Physical Examinations 
- 
Vital signs 
- 
12-Lead Electrocardiograms (ECGs) 
- 
Echocardiograms/MUGA scans 
- 
LVEF monitoring 
 
Adverse events (AEs) assessment will begin at time of signing informed consent through Day 28 visit following 
the last study treatment. Adverse events which are assessed as possibly, probably, or definitely related to study 
treatment will be recorded at any point during the trial and must be followed until resolution or the subject is 
clinically stable. 
 
Other safety data including physical examinations, vital signs, 12-Lead ECGs, echocardiograms/MUGA scans, 
LVEF monitoring and hematology, clinical chemistry, and urinalysis will be assessed through Day 28 following 
study treatment. 
 
To provide surveillance for any late hematologic, cardiac, or liver toxicity, the following additional safety 
assessments will be done: 
 
- 
Physical examination, assessment of vital signs, ECGs, CBC with differential, serum chemistry, PT/INR 
and urinalysis at Month 5, Month 9, and Month 13 or at disease progression, whichever occurs first. 
- 
LVEF monitoring at Month 13 or at disease progression, whichever occurs first 
- 
Serum chemistry and PT/INR assessments at Month 17, Month 21, and Month 25 (+/- 2 weeks) or at 
disease progression, whichever occurs first. 
 
Subjects with elevated bilirubin levels > 2.0 mg/dL and ≤ 3.0 mg/dL at baseline will return to the clinic on Day 7 
for additional safety assessments. 
 
 
 
6. 
STATISTICAL METHODOLOGY 
 
6.1 
Statistical and Analytical Issues 
 
6.1.1 Statistical Methods 
 
Continuous variables will be described in terms of mean, standard deviation, median, minimum, and maximum 
for each treatment arm. Qualitative variables will be presented in terms of frequency and percent for each treatment 
arm. 
 
In summary and analysis tables of continuous variables, the minimum and maximum statistics will be presented 
to the same number of decimal places as the original data. The mean, median, quartiles, and 2-sided 95% 
confidence interval (CI) will be presented to 1 more decimal place than the original data. The standard deviation 
and standard error will be presented to 2 more decimal places than the original data. 


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In summary tables of categorical variables, the number of non-missing observations and percentages will be 
presented. The denominator for each percentage will be the number of subjects within the population of the 
treatment arm (unless otherwise specified). 
 
Baseline characteristics and the efficacy parameters will be summarized for the ITT population while the safety 
parameters will be summarized for the As-Treated population. 
 
All statistical analyses will be performed using SAS® v9.4 or higher. 
 
6.1.2 Handling of Dropouts and Missing Data 
 
6.1.2.1 Dropouts 
 
Subjects who complete the Day 0 procedures but withdraw prior to the Follow-up Period will not be replaced 
 
6.1.2.2 Missing Data 
 
All analysis will be based on available data to summarize safety and efficacy results. However, a conservative 
approach to partial dates and missing adverse event’s relationships will be as follows: 
- 
For the OS analyses, if a subject’s death month and year are provided but the day is missing, the day will 
set to the first day of the month, unless other qualifying study data support survival until a later date in 
the same month. The same concept will be applied if only the year is known. For a completely missing 
date of death, the fatality will be imputed to have been occurred on the last available contact of the subject 
where we still know he/she was alive. 
- 
Adverse events with partial dates with the same month and year as the Procedure Day 0 will be considered 
as treatment-emergent adverse events. 
- 
If an adverse event’s relationship is missing it will be assumed to be related. 
 
6.1.3 Pooling of Investigator Sites 
 
Data will be pooled from centers for these analyses. The justification for pooling is made on a clinical basis 
(Meinert, 1986). The basis for pooling comes from three critical factors: 1) The study sites must implement one 
common protocol. 2) The sponsor must provide very close monitoring of study site compliance. 3) The study 
sites must use common data collection procedures. 
 
However, region (EU and US, China, Korea, other) will be included as a factor in supportive and exploratory CPH 
analyses for OS and PFS, as well as safety analyses. 
 
6.1.4 Determination of Sample Size 
 
The study is designed to detect with 80% power a hazard ratio for OS of 0.67 (33% risk reduction) in the 
ThermoDox (TR) arm compared with the control (PR) arm with an overall 1-sided type 1 error of 0.025. An OS 
hazard ratio of 0.63 was observed among Celsion’s initial phase III trial, the HEAT study (Protocol 104-06- 
301) subjects with a solitary 3-7 cm lesion treated with ≥ 45 minutes of RFA. A 3%/year loss to survival follow- 
up rate has been assumed and using a 1:1 treatment allocation (TR:PR) of 550 subjects, a target of 197 events 
(deaths) will be required for the primary analysis. 


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Based on these design operating characteristics and assuming a median survival time of approximately 4.5 years 
in the control arm, the primary analysis target events milestone will be reached approximately 30 months after the 
last subject is randomized in the study. The median OS in the control arm was estimated based on the interim OS 
results in the HEAT study. 
 
6.2 
Subject Disposition, Baseline and Treatment Characteristics 
 
6.2.1 Subject Disposition 
 
The number of subjects in each study population and the reasons for exclusion, along with any randomization 
and/or stratification errors will be summarized by treatment arm. In addition, subjects that discontinue study 
treatment or study follow-up will also be summarized, along with reasons for study discontinuation. 
 
The number of screening failures, and the reason, will be tabulated. 
 
6.2.2 Protocol Deviations 
 
 
CSR Reportable 
 
A CSR reportable Protocol Deviation is related to inclusion/exclusion criteria, conduct of the trial, patient 
management or patient assessments that impact the safety of the subjects or jeopardize the quality of the study 
data. 
 
The following classifications will be used to report CSR reportable Protocol Deviations: 
RD1 - A subject that did not meet entry criteria 
RD2 - A subject that developed withdrawal criteria but was not withdrawn 
RD3 - A subject that received the wrong treatment or incorrect dose 
RD4 - A subject that received an excluded medication 
RD5 - Critical ICF, GCP and other Protocol Deviations 
 
 
Major CSR Reportable Protocol Deviations 
 
In addition, among all CSR Reportable Protocol Deviations, a set of “major protocol deviations” is defined as a 
means to measure adherence to key aspects of the protocol using prespecified sensitivity analyses. 
A summary of all major protocol deviations (at study entrance and during the study period) by type of deviation 
will be provided. 
A patient will be classified as having a major protocol CSR reportable deviation  if she/he meets at least one of 
the criteria presented below. 
 
MRD1 - No HCC lesions 
MRD2 - single HCC lesion < 3.0 or > 7.0 cm or multiple lesions 


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MRD3 - ECOG performance status at baseline not 0 
MRD4 - Not a Child-Pugh A classification 
MRD5 - baseline platelets < 75,000/mm3 
MRD6 - RFA start time > 20 minutes from start of infusion 
MRD7 - RFA dwell time < 45 minutes 
 
CSR Non-Reportable 
 
A CSR non-reportable Protocol Deviation may be important to address and document as part of site 
management and oversight, but will not be considered reportable in the CSR. 
 
The following classifications will be used to capture non-reportable PDs. 
NRD1 - SAE reporting 
NRD2 - Informed consent (other than those captured above) 
NRD3 - Study procedures 
NRD4 - Investigational product (other than incorrect dose or wrong treatment) 
 
 
 
6.2.3 Subject Baseline Characteristics 
 
Demographic data (age, race, gender) will be summarized by treatment arm for the ITT and AT population. 
 
Subject characteristics such as height (in cm), weight (in kg), ECOG performance and disease history reported at 
the Screening/Baseline visit will be summarized by treatment arm for the ITT population. 
Data listings will present the demographic and baseline characteristic data. 
 
6.2.4 Treatment Exposure and Compliance 
 
The study treatment administration and compliance profile will be summarized descriptively by treatment arm for 
the AT population and displayed in data listings. 
 
6.2.5 Prior and Concomitant Medications and Therapies 
 
Prior and concomitant medications will be coded according to the World Health Organization (WHO) 
Medication Dictionary for Concomitant Medication. 
 
Prior and concomitant medications will be summarized descriptively by treatment arm for the ITT population 
and displayed in data listings. 
 
6.2.6 Medical Histories 
 
Medical history including cancer and non-cancer history data listing will be presented by treatment arm for the 
ITT population. 


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6.2.7 Follow-up Period 
 
Duration of Follow-up for Survival: 
 
A summary table showing the duration of follow-up will be presented by treatment arm for the ITT population. 
The follow-up period is defined as the time starting on the date randomized until the last day of contact, or the 
day of withdrawal from study or the day of death, whichever occurs last. 
 
Non-study anti-cancer treatment during follow-up period: 
 
Patients receiving non-study anti-cancer treatments initiated during the follow-up period will be summarized in a 
table by treatment arm. The table will display the number, type and time to starting a new non-study anti- 
cancer treatment. The summary table will also show the number of patients starting a new anti-cancer treatment 
without having experienced documented radiological progression by the investigator. The time to start of the 
new anti-cancer treatment will be defined as the start date of the new anti-cancer therapy minus the date of last 
dose of study medication + 1.  If the start date of the new anti-cancer treatment is missing, the time to start of 
anti-cancer therapy will be missing for that patient. 
 
6.3 
Efficacy Analysis 
 
6.3.1 Primary Efficacy Variable(s) 
 
Overall survival will be measured by time (in months) from randomization to death from any cause or the end of 
the study. Subjects who have not died will be censored at the date of last study follow-up, or the cut-off date, 
whichever is earlier as mentioned in Section 3. 
 
The OS cut-off date used for the primary analysis will be based on the observations of the 197th death in the 
study. All patients dying on the calendar date of the 197th death will be included in the analysis should more 
than one patient die on the calendar date of the 197th death. Patients having a documented survival status (alive 
or dead) after this date are censored at the cut-off date. 
With the OS cut-off date being event driven, for operational efficiency, the cut-off date for all other study 
endpoints (e.g., PFS) will be fixed at close proximity of the OS cut-off date, when the milestone is nearing 
completion. This especially applies to the interim analyses. 
 
OS in the ITT population will be compared between the 2 treatment arms using the stratified log-rank test (Score 
statistic from PHREG and ties=Breslow (Kalbfleisch and Prentice 1980)). The estimate of the hazard ratio and 
corresponding 95% CI will be provided using a Cox proportional hazards (CPH) model including treatment and 
the stratification factors (maximum lesion diameter [3-5 cm versus >5–7 cm] and RFA route [laparoscopic, open 
surgical, percutaneous]) in the model. The survival curves will be estimated using Kaplan-Meier estimates. The 
stratification factors will be populated as per the randomization assignment. 
 
Survival for each arm will be summarized using Kaplan Meier curves and is further characterized in terms of the 
median and survival probability at 12, 24, 36, 48, 60 and 72 months, along with the corresponding 2-sided 95% 
confidence intervals for the estimates. Confidence intervals for median survival are based upon the methods of 
(Brookmeyer and Crowley 1982). In addition to Kaplan-Meier estimates, corresponding 2-Sided 95% 


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confidence intervals constructed using the Clopper-Pearson approximation to the exact binomial proportion 
(Hollander and Wolfe 1973). 
 
For the first interim analysis, if there are more than 129 events (118+10%), an additional table will be presented 
for sensitivity purposes, based only on the first 118 events. The same principle applies for the second interim 
analysis, accordingly. 
 
6.3.2 OS Supportive Analyses 
 
Supportive analyses for OS, conducted in the ITT population (unless otherwise noted), will include: 
 
a. The unstratified log-rank test and a CPH model (only treatment effect in the model). 
 
b. Multivariate analysis using the CPH model, including the stratification factors and the following set of 
potential prognostic/predictive factors: age (< 65 v. ≥ 65), race (Caucasian, Asian, Other), region (EU and 
America, China All, Korea, Other), RFA start time, RFA dwell time (< 90 min, ≥ 90 min), device, disease 
etiology (Hep B, Other), ECOG Performance Status (0, 1, 2, 3, 4, 5), Alfa-feto protein >200 ng/mL 
(yes/no). 
 
c. Factors included in the model will be assessed for co-linearity and a stepwise selection process will be 
applied to identify a final subset of prognostic/predictive factors in the model. Once the subset has been 
established, treatment will be added to the final model to assess its effect. An exploratory analysis of 
treatment by factor interactions using the CPH model will be conducted, using the factors identified in 
the final model above. 
 
d. Subgroup analyses will also be conducted for the stratification factors and the potential 
prognostic/predictive factors identified in Section 6.33.b above. The HR and associated 95% CI will be 
presented for each subgroup. 
 
e. The primary efficacy analysis, as outlined in Section 6.3.1, will also be run excluding any subjects that 
met the Major CSR Reportable Protocol Deviation criteria MRD1 to MRD7 as outlined in Section 6.2.2. 
 
f. A stratified log-rank test using the final strata as recorded on the CRF, in the event there are differences 
from the primary IVRS assignments. (AT population) 
 
g. Additional exploratory analyses may be performed. 
 
In addition, a study follow-up Kaplan-Meier analysis (as for OS) will be presented for all subjects. Subjects will 
be censored if they have died, on their date of death. Only median, 25th and 75th percentiles will be presented. 
 
6.3.3 Secondary Efficacy Variable(s) 
 
PFS will be measured from the date of randomization to the first date on which one of the following occurs, as 
determined by CT or MRI scan: 
• 
Death of any cause 
• 
Treatment failure (inability to achieve Complete Response (CR) after two RFA ± ThermoDox treatment 
sessions) 
• 
Progression due to local tumor recurrence after initial CR 


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• 
Progression due to distant intrahepatic tumor recurrence 
• 
Progression due to extrahepatic tumor recurrence 
 
All secondary endpoints comparisons will be made at the 2-sided 0.05 significance level for the ITT population. 
Since PFS is the only secondary endpoint for regulatory registration purposes, no further multiplicity adjustments 
will be made. Assuming that OS demonstrates significance at the 1-sided 0.025 level, PFS can subsequently be 
tested at the 1-sided 0.025 level. 
 
PFS will be analyzed with methodology applied to the OS endpoint. Specifically, PFS will be analyzed with the 
methodology specified in Section 6.3.1 and the supportive analyses in Section 6.3.2. 
 
In line with FDA guidance (Clinical Trial Endpoints for the Approval of Cancer Drugs and Biologics, 2007), 
several sensitivity analyses for Progression-Free Survival are also conducted on the ITT Population as follows: 
 
• 
Analysis that includes clinical progression as a PFS event in addition to the presence of radiological 
evidence of progression. 
 
• 
Analysis including clinical progression as a PFS event that also counts initiation of non-study antitumor 
therapy as an event date rather than as date used to censor subsequent response assessments. (ITT 
population) 
 
• 
An analysis that includes all death and response assessments (without censoring missed visits) and also 
counting as an event, clinical progression, the initiation of anti-tumor therapy or death through the date 
of cut-off for survival (ITT population) 
 
• 
Analysis using the next scheduled visit as the event date for radiological progression when image 
assessment falls more than 1 month after a scheduled assessment. If reassignment of the progression date 
to the next scheduled visit results in a progression date after death, the death date is used as the event date. 
(ITT population) 
 
• 
Kaplan-Meier curves of time to first, second, third, fourth and fifth radiological tumor assessments from 
date of randomization are done and compared between groups using the log-rank test. (ITT population) 
 
6.4 
Safety Analysis 
 
The safety evaluations will focus primarily on AEs and laboratory assessments, but will also include physical 
examinations, vital signs, ECGs, echocardiograms/MUGA scans and LVEF testing. All subjects included in the 
As-Treated population will be summarized by treatment arms in the safety analysis. 
 
6.4.1 Treatment-Emergent Adverse Events 
 
Treatment-emergent adverse events will be coded according to the Medical Dictionary for Regulatory Activities 
(MedDRA) terminology and the severity of the toxicities will be graded according to the NCI CTCAE criteria, 
v4.03, where applicable. 
 
All TEAEs will be summarized (incidence) and listed by the System Organ Class (SOC), preferred term, 
toxicity/severity grade, and causal relationship to study medication by treatment arm. In addition, separate 


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summaries of serious treatment-emergent adverse events (SAEs) and Grade 3 and 4 TEAEs will be presented by 
treatment arm. 
 
Further, AE tabulations will be repeated using the following subgroups: 
• 
Age Category at Screening (<65 years/>=65 Years) 
• 
Gender (male/female), 
• 
Ethnicity (Asian/Caucasian/Other), 
• 
Region (America and Europe/China All/Asia Other), and 
• 
Lesion Size (<5 cm/>=5cm) 
• 
RFA Dwell Duration (<90, >=90 min) 
 
6.4.2 Laboratory Parameters 
 
Hematological and chemistry laboratory parameters will be graded according to the NCI CTCAE v.4.03 criteria 
(see appendix), where applicable. Absolute values and changes from baseline will be summarized by treatment 
arm at each visit. Shift tables will be provided for the shift from Baseline to the highest post Baseline value. The 
last on-study value will also be presented (called ‘End of Study’), with change from baseline. In addition, worst 
severity grade, time to event, and time to resolution will also be summarized. 
 
6.4.3 Physical Examination 
 
The physical exam data will be listed by treatment arm at the screening visit, at post RFA on Day 0, Day 7 for 
subjects with elevated bilirubin, Day 14, Day 28, Month 5, Month 9, Month 13 or disease progression, 
whichever occurs first. 
 
6.4.4 Vital Signs 
 
Vital signs, (temperature (in Celsius), blood pressure, pulse rate, and respiration) will be collected at the 
screening visit, Day 0: pre-dose assessment the morning of the RFA procedure, post-RFA within 15 minutes 
after completion of study drug infusion, within 30 minutes and 1 hour after RFA procedure, then every 2 hours 
until the subject is stable or discharged, Day 7 for subjects with elevated bilirubin, Day 14, Day 28, Month 
5, Month 9, Month 13 or disease progression, whichever occurs first. 
 
Vital signs will be summarized at each visit by treatment arm for actual values and change from baseline. The 
last on-study value will also be presented (called ‘End of Study’), with change from baseline. 
 
6.4.5 12-Lead ECGs 
 
12- Lead ECGs will be acquired at screening, post Day 0: post RFA, Day 28, Month 5, Month 9, and Month 
13 or disease progression, whichever occurs first. 
 
For all12-lead ECG abnormal findings will be presented for the actual values and change from baseline by visit 
and treatment arm. 
 
Frequency tables will be provided by visit for QTcB and QTcF for the following categories: 
• 
QTc <= 450 ms 
• 
450 ms < QTc <= 480 ms 


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• 
480 ms < QTc <= 500 ms 
• 
QTc > 500 ms 
 
Frequency tables will be provided by visit for the changes from baseline of QTcB and QTcF for the following 
categories: 
• 
QTc change from baseline <= 30 ms 
• 
30 ms < QTc change from baseline <= 60 ms 
• 
QTc change from baseline > 60 ms 
 
6.4.6 Echocardiograms/MUGA scans for LVEF monitoring 
 
A baseline echocardiogram (ECHO) will be carried out at the screening visit. Measurements with a MUGA scan 
are allowed if an echocardiogram cannot be performed; however, the same modality used at baseline must be used 
on Day 28 and at Month 13 or at time progression of disease, whichever occurs first. 
 
Counts and percentages of abnormal echocardiograms/MUGA scan will summarized for each treatment arm at 
each visit. 
 
LVEF monitoring will be assessed at screening, Day 0: post RFA, Day 28, Month 5, Month 9, and Month 13 
or disease progression, whichever occurs first. 
 
LVEF % will be summarized by treatment arm at each visit for actual values and change from baseline. 
 
6.5 
Data Monitoring Committee 
 
An independent Data Monitoring Committee (DMC) will periodically assess the safety data as well as the 
efficacy as part of the interim analyses described in Section 6.6. A description of the roles and responsibilities 
and details of the review processes are provided in a separate DMC charter. 
 
6.6 
Interim Analysis 
 
Two interim analyses reviewed by the DMC, both for efficacy and futility, are planned for the study. The first is 
planned after 60% of the target events is reached (118 deaths) and the second after 80% of the events has been 
reached (158 deaths). The Lan-DeMets alpha-spending approach will be used with O'Brien-Fleming stopping 
boundaries to evaluate efficacy. Fixed HR boundaries will be used to assess futility. This approach will account 
for multiple testing and preserve the overall 1-sided study significance level of 0.025. Additional details are 
provided in the DMC charter. 
 
No futility analyses are planned during the accrual period. Considering the relative short time of the accrual period 
compared to the slower accumulation rate of the events, there will not be sufficient events to make such assessment 
in the accrual study stage. 
 
 
 
7. 
TABLES, LISTINGS, AND FIGURES LAYOUT 
 
The default tables, listings and figures (TLF) layout will be as follows. 


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Orientation 
Landscape 
Paper Size 
Letter 
Margins 
Top: 3.2 cm 
Bottom: 2.5 cm 
Left: 2.5 cm 
Right: 2.5 cm 
Font 
Courier New 9pt 
Headers 
Sponsor name and Protocol number (Left); Page X of Y 
(Right) 
TLF Number and Title 
Footers 
SAS program path and file name 
Date, Time TLF generated 
 
The font size may be reduced as necessary to allow additional columns to be presented, but not at the expense of 
clarity.  Also, the orientation may be changed to portrait if appropriate. 
 
The date format for all presentations will be ‘DDMMMYYYY’. 
 
All TLF outputs will be generated using SAS® v9.4 or higher for Windows. 
 
CRF data collected will be presented within data listings.  The data listings will be sorted by treatment arm, site 
number, subject number, visit, and time point. 
 
 
 
8. 
LIST OF TABLES, LISTINGS AND FIGURES 
 
The list of tables, listings and figures will be provided in a separate document. 
 
 
 
9. 
REFERENCES 
 
1. 
Chen MH, Wei Y, Yan K, Gao W, Dai Y, Huo L, et al. Treatment of strategy to optimize radiofrequency 
ablation for liver malignancies. J Vasc Interv Radiol. 2006;17(4):671-83. 
2. 
Chen MS, Li JQ, Zheng Y, Guo RP, Liang HH, Zhang YQ, et al. A prospective randomized trial 
comparing percutaneous local ablative therapy and partial hepatectomy for small hepatocellular 
carcinoma. Ann Surg. 2006;243(3):321-8. 
3. 
Chen MH, Yang W, Yan K, Zou MW, Solbiati L, Liu JB, et al. Large liver tumors: protocol for 
radiofrequency ablation and its clinical application in 110 patients - mathematic model, overlapping mode, 
and electrode placement process. Radiology. 2004;232(1):260-71. 
4. 
Curley SA. Radiofrequency ablation of malignant liver tumors. Oncologist 2001; 6:14-23. 


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5. 
Dodd GD 3rd, Frank MS, Aribandi M, Chopra S, Chintapalli KN. Radiofrequency thermal ablation: 
computer  analysis of  the size  of  the  thermal  injury  created  by  overlapping  ablations.  AJR Am J 
Roentgenol. 2001;177(4):777-82. 
6. 
Kim WR, Gores GJ, Benson JT, Therneau TM, Melton LJ 3rd. Mortality and hospital utilization for 
hepatocellular carcinoma in the United States. Gastroenterology. 2005;129(2):486-93. 
7. 
Llovet JM, Di Bisceglie AM, Bruix J, Kramer BS, Lencioni R, Zhu AX, et al. Design and endpoints of 
clinical trials in hepatocellular carcinoma. J Natl Cancer Inst. 2008;100(10):698-711. 
8. 
Meinert, C. (1986). Clinical Trials: Design, Conduct, and Analysis. Oxford University Press, New York. 
9. 
Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005;55:74-108. 
10. 
Thomas MB, Abbruzzese JL. Opportunities for targeted therapies in hepatocellular carcinoma. J Clin 
Oncol. 2005;23:8093-108. 
11. 
Uka K, Aikata H, Takaki S, Shirakawa H, Jeong SC, Yamashina K, et al. Clinical features and prognosis 
of patients with extrahepatic metastases from hepatocellular carcinoma. World J Gastroenterol. 
2007;13(3): 414-20. 
12. 
Yang Y, Nagano H, Ota H, Morimoto O, Nakamura M, Wada H, et al. Patterns and clinicopathologic 
features of extrahepatic recurrence of hepatocellular carcinoma after curative resection. Surgery. 
2007;141(2):196-202 
13. 
Kalbfleisch, J. D. and Prentice, R. L. (1980), The Statistical Analysis of Failure Time Data, New York: 
John Wiley & Sons, Inc. 
14. 
Brookmeyer and Crowley, A Confidence Interval for the Median Survival Time, Biometrics 38, 29-41, 
March 1982. 
15. 
Hollander and Wolfe, D. A.: Nonparametric Statistical Methods, Wiley 1973. 
16. 
Clinical Trial Endpoints for the Approval of Cancer Drugs and Biologics. FDA, May 2007. Web. 27 
Mar.2014. 
http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm071590.pdf 


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10. 
APPENDICES 
 
10.1 Standard Laboratory Ranges 
 
Table 10.1.1. Standard Normal Ranges for Hematological Tests 
 
Hematology Laboratory Test 
Unit 
Normal Range 
Hemoglobin 
g/L 
120 - 170 
Hematocrit 
% 
37 - 50 
Platelets 
x 103/uL 
110 - 450 
RBC 
x 106/uL 
4 - 6.2 
WBC 
x 103/uL 
3.5 - 11 
Neutrophil, Absolute 
x 103/uL 
2.0 – 7.0 
Lymphocytes, Absolute 
x 103/uL 
0.9 - 3.5 
Monocytes, Absolute 
x 103/uL 
0.12 – 0.9 
Eosinophils, Absolute 
x 103/uL 
0 – 0.66 
Basophils, Absolute 
x 103/uL 
0 – 0.2 
 
 
Table 10.1.2. Standard Normal Ranges for Serum Chemistry Tests 
 
Serum Chemistry Laboratory Test 
Units 
Normal Range 
Sodium 
mEq/L 
132 - 145 
Potassium 
mEq/L 
3.4 - 5.4 
Chloride 
mEq/L 
94 - 112 
Albumin 
g/L 
33 - 49 
Calcium 
g/L 
0.083 – 0.106 
BUN 
g/L 
0.04 – 0.24 
Bilirubin 
g/L 
0.002 – 0.012 
Bilirubin, indirect 
mg/dL 
0.1 – 1.0 
Alkaline Phosphatase 
units/L 
35 - 127 
AST (SGOT) 
units/L 
5.0 - 50 
ALT (SGPT) 
units/L 
5.0 - 40 
Creatinine 
g/L 
0.005 – 0.012 
Glucose 
g/L 
0.7 – 1.00 


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10.2 NCI CTCAE Laboratory Grades 
Table 10.2.1   NCI CTCAE V4.03 LAB GRADES 
 
Lab Test 
Unit 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
SERUM CHEMISTRIES + COAGULATION 
Albumin (hypoalbuminemia) 
g/dL 
[3, LLN) 
[2, 3) 
[0, 2) 
UNDEFINED 
Alkaline Phosphatase 
units/L 
(ULN, 2.5*ULN] 
(2.5*ULN, 5*ULN] 
(5*ULN, 20*ULN] 
>20*ULN 
ALT 
units/L 
(ULN, 3.0*ULN] 
(3.0*ULN, 5*ULN] 
(5*ULN, 20*ULN] 
>20*ULN 
AST 
units/L 
(ULN, 3.0*ULN] 
(3.0*ULN, 5*ULN] 
(5*ULN, 20*ULN] 
>20*ULN 
Amylase 
units/L 
(ULN, 1.5*ULN] 
(1.5*ULN, 2*ULN] 
(2*ULN, 5*ULN] 
>5*ULN 
Bilirubin 
mg/dL 
(ULN, 1.5*ULN] 
(1.5*ULN, 3*ULN] 
(3*ULN, 10*ULN] 
>10*ULN 
Calcium max (Hypercalcemia) 
mg/dL 
(ULN, 11.5] 
(11.5, 12.5] 
(12.5, 13.5] 
>13.5 
Calcium min (Hypocalcemia) 
mg/dL 
[8, LLN) 
[7, 8) 
[6, 7) 
[0, 6) 
Cholesterol (Hypercholesterolemia) 
mg/dL 
(ULN, 300] 
(300, 400] 
(400, 500] 
>500 
CK 
unit/L 
(ULN, 2.5*ULN] 
(2.5*ULN, 5*ULN] 
(5*ULN, 10*ULN] 
>10*ULN 
Creatinine 
mg/dL 
(ULN, 1.5*ULN] 
(1.5*ULN, 3*ULN] 
(3*ULN, 6*ULN] 
>6*ULN 
GGT 
units/L 
(ULN, 2.5*ULN] 
(2.5*ULN, 5*ULN] 
(5*ULN, 20*ULN] 
>20*ULN 
Glucose max (hyperglycemia) 
mg/dL 
(ULN, 160] 
(160, 250] 
(250, 500] 
>500 
Glucose min (hypoglycemia) 
mg/dL 
[55, LLN) 
[40, 55) 
[30, 40) 
[0, 30) 
Lipase 
units/dL 
(ULN, 1.5*ULN] 
(1.5*ULN, 2*ULN] 
(2*ULN, 5*ULN] 
>5*ULN 
Fibrinogen 
mg/dL 
[0.75*LLN, LLN)  or 
decreased from baseline by 
>0 to 25% 
[0.5*LLN, 0.75*LLN) or 
decreased from baseline by 
25 to <50% 
[0.25*LLN, 0.5*LLN) or 
decreased from baseline by 50 to 
<75% 
[0, 0.25*LLN) 
or 
decreased from baseline by ≥75% 
or <50 mg/dL 
Magnesium max (Hypermagnesemia) 
mg/dL 
(ULN, 3] 
UNDEFINED 
(3, 8] 
>8 
Magnesium min (Hypomagnesemia) 
mg/dL 
[1.2, LLN) 
[0.9, 1.2) 
[0.7, 0.9) 
[0, 0.7) 
Phosphates (hypophosphatemia) 
mg/dL 
[2.5, LLN) 
[2, 2.5) 
[1, 2) 
[0, 1) 
Potassium max (hyperkalemia) 
mEq/L 
(ULN, 5.5] 
(5.5, 6] 
(6, 7] 
>7 
Potassium min (hypokalemia) 
mEq/L 
[3, LLN) 
UNDEFINED 
[2.5, 3) 
[0, 2.5) 
PT 
Seconds 
(ULN, 1.5*ULN] 
(1.5*ULN, 2.5*ULN] 
>2.5*ULN 
UNDEFINED 
INR 
(ULN, 1.5*ULN], >1 - 1.5 
times above baseline if on 
anticoagulation 
(1.5*ULN, 2.5*ULN], >1.5 - 
2.5 times above baseline if on 
anticoagulation 
>2.5*ULN, >2.5 times above 
baseline if on anticoagulation 
UNDEFINED 
PTT 
Seconds 
(ULN, 1.5*ULN] 
(1.5*ULN, 2.5*ULN] 
>2.5*ULN 
UNDEFINED 
Sodium max (hypernatremia) 
mEq/L 
(ULN, 150] 
(150, 155] 
(155, 160] 
>160 
Sodium min (hyponatremia) 
mEq/L 
[130, LLN) 
UNDEFINED 
[120, 130) 
[0, 120) 
Triglycerides  (Hypertriglyceridemia) 
mg/dL 
(150, 300] 
(300, 500] 
(500, 1000) 
>=1000 
Uric Acid (hyperuricemia) 
mg/dL 
(ULN, 10] 
UNDEFINED 
UNDEFINED 
>10 


CONFIDENTIAL 
Version 3.0 Date: 16 June 2020 
Page 23 of 23 
STATISTICAL ANALYSIS PLAN 
Celsion Corporation 
104-13-302 
Page 23 
 
 
 
 
 
Lab Test 
Unit 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
HEMATOLOGIES 
Hemoglobin (High) 
g/dL 
Increase in >0 - 2 gm/dL 
above ULN or above baseline 
if baseline is above ULN 
Increase in >2 - 4 gm/dL 
above ULN or above baseline 
if baseline is above ULN 
Increase in >4 gm/dL above ULN or 
above baseline if baseline is above ULN 
UNDEFINED 
Hemoglobin (Low) 
g/dL 
[10, LLN) 
[8, 10) 
[0, 8) 
UNDEFINED 
Platelet 
10^3/uL 
[75, LLN) 
[50, 75) 
[25, 50) 
[0, 25) 
WBC (High) 
10^3/uL 
UNDEFINED 
UNDEFINED 
>100 
Undefined 
WBC (Low) 
10^3/uL 
[3, LLN) 
[2, 3) 
[1, 2) 
[0, 1) 
Lymphocytes (High) 
10^3/uL 
UNDEFINED 
(4 – 20] 
>20 
UNDEFINED 
Lymphocytes (Low) 
10^3/uL 
[.8, LLN) 
[.5 - .8) 
[.2 - .5) 
[0,.2) 
Neutrophils 
10^3/uL 
[1.5, LLN) 
[1, 1.5) 
[.5, 1) 
[0, .5) 
 
 
LLN=Lower Limit of Normal;  ULN=Upper Limit of Normal; 
 
a Grade 4 criteria do exist for AE reporting based on clinical manifestations of leukocytosis needing urgent intervention. Not included in the 
programmed grading of laboratory data but is applicable to AE reporting.