Conditions: Pediatric Neurosurgical Tumors
Keywords: Sodium Fluorescein Surgical Microscope Central Nervous System Tumors
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 2
Healthy volunteers: no

Brief summary:
Sodium fluorescein, which has been shown to be useful for intraoperative guidance regarding the resection of adult neurosurgical tumors, can aid the resection of pediatric neurosurgical tumors.

Detailed description:
This study will be a prospective non-randomized cohort study with patients presenting to Children's Hospital Colorado for resection of a central nervous system tumor. This study will employ the use of sodium fluorescein and an FDA approved operative microscope equipped with excitation and barrier filters for monitoring with sufficient fluorescent enhancement and contrast. Fluorescein sodium is a small organic salt that accumulates in areas of diminished blood-brain barrier integrity and allows for determination of the margins between tumor and normal brain function.

Arms:
arm 1: This study will employ the use of sodium fluorescein and an FDA approved operative microscope equipped with excitation and barrier filters for monitoring with sufficient fluorescent enhancement and contrast.

Interventions: intervention 1: Sodium Fluorescein intervention 2: Microscopic Resection
Intervention descriptions: intervention 1: Patients enrolled in this study will receive 3 mg/kg sodium fluorescein following induction of anesthesia by administration into a peripheral venous line over 10 seconds intervention 2: Resection will proceed with the use of a surgical microscope equipped with excitation and barrier filters for monitoring with sufficient fluorescent enhancement and contrast.

Protocol document:
Prot_SAP_ICF_000.pdf: 
Protocol #18-0242 
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Project Title: Sodium Fluorescein-guided resection of pediatric neurosurgical tumors 
 
Principal Investigator:  Todd Hankinson MD, MBA 
Protocol #: 18-0242 
Version Date:  June 28,2021 
 
 
 
 
 
 
  
 
 
I. Hypotheses and Specific Aims:   
 
Hypothesis: Sodium fluorescein, which has been shown to be useful for intraoperative guidance 
regarding the resection of adult neurosurgical tumors, can aid the resection of pediatric 
neurosurgical tumors.  
 
Specific Aims: To study the utility of sodium fluorescein when used in conjunction with a surgical 
microscope equipped with fluorescent filters in the resection of pediatric central nervous system 
tumors (i.e. brain tumors and spinal tumors).  
 
 
II. Background and Significance:  
 
Several techniques using fluorescent biomarkers have been investigated as means to identify and 
delineate brain tumors from critical neural and vascular structures, and to facilitate resection of 
multiple types of adult brain tumors. In certain tumor types, such as adult gliomas, extent of 
resection is a primary determinant of outcome and is associated with longer life expectancy [1]. 
Unfortunately, glioma heterogeneity and the diffuse infiltrative nature of the tumors make complete 
resection difficult. Thus, in glioma as well as other types of nervous system tumors, improving the 
intraoperative detection of residual tumor while preserving normal tissue is crucial. Consequently, 
methods that can aid in achieving gross total resection while minimizing the risk of damaging 
normal adjacent tissue are of clinical significance and direct utility to patients. Currently, multiple 
surgical adjuncts exist, including intraoperative ultrasound, frameless sterotaxy, and intraoperative 
MRI. 
 
Recent research in fluorescein-guided microsurgery has emerged as an additional adjunct to these 
tools. The two most commonly used and researched agents are 5-ALA and sodium fluorescein. 5-
ALA is a metabolic precursor protein to the heme biosynthesis pathway that leads to the 
accumulation of a fluorescent protein, protoporphyrin IX, in gliomas when administered 
exogenously [2]. In their study, Stummer et al. examined the use of 5-ALA to determine if its use 
would lead to better tumor visualization, more complete resection, and potentially increased 
survival. They concluded that in addition to age, residual solid fluorescence and absence of 
contrast enhancement on post-operative MRI were independent explanatory factors for survival. 
The authors concluded that 5-ALA-induced tumor fluorescence was useful for guiding tumor 
resection. 5-ALA however is very expensive and currently not FDA approved for surgical resection 
of central nervous system tumors. 
 
Sodium fluorescein is an exogenous green fluorescent contrast agent whose use has been mostly 
limited to ophthalmologic angiography for the diagnosis of malignancies and vascular lesions. 
Sodium fluorescein was first used in neurosurgery in 1948 and has been found to be safe for use in 
neurosurgery [3,5,7]. The use of systemically-delivered intra-operative fluorescein has been 
evaluated in gliomas (low-grade and high-grade), metastatic tumors, and various skull base lesions 
including schwannoma, meningioma, craniopharyngioma, and pituitary adenoma [6-13]. Koc et al. 
compared the influence of fluorescence guided resection in gliomas on gross total resection and 
survival in patients versus those who underwent standard microsurgical resection and found that 
the extent of fluorescence had a powerful effect on the rate of gross total resection (83% vs. 55%) 
despite no statistically significant difference in survival between the groups. Okuda et al., found that 
the use of fluorescein-guided resection may reduce the rate of local recurrence in patients with 
metastatic lesions, and da Silva et al., introduced the possibility of using fluorescein-guided 


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resection in skull base surgery for various lesions [11,14]. Recent groups have taken the concept of 
fluorescein-guided resection further by developing a microscope capable of emitting excitatory light 
and detecting fluorescence from sodium fluorescein in an effort to further maximize resection rates 
[12]. 
 
Significantly, systemically delivered sodium fluorescein has been found to be useful in guiding the 
resection of adult central nervous system tumors and has been found to be safe and effective as 
an intraoperative tool. Thus far, there has been a paucity of research exploring the usefulness of 
sodium fluorescein in the surgical resection of pediatric tumors [15].  
 
Particular advantages may exist in the resection of spinal tumors, for which other operative 
adjuncts (e.g. neuronavigation) are not available. Spinal cord anatomical and physiological 
composition is very similar to the composition of the brain. The blood brain barrier is also present in 
the spinal cord of adults and pediatric patients and is composed of astrocytes. Tumors within the 
spine cause disruption of the spinal cord blood brain barrier and permit for extravasation of both 
contrast as well as sodium fluorescein [5]. In the absence of tumors, sodium fluorescein does not 
non-specifically extravasate into the parenchyma and this has been shown in spinal vascular 
applications [5,11,16]. Our institution has demonstrated safe administration and use of sodium 
fluorescein in adult spinal populations and we plan to apply this to our pediatric patient population 
as well. [17,18] We will utilize a phased method of enrollment and enroll patients with spinal lesions 
into the second phase of our study. Pediatric patients have a relatively high incidence of spinal 
tumor and would benefit from the use of sodium fluorescein which may prove to be crucial in the 
maximal safe resection of these lesions.  
 
 
III. Preliminary Studies/Progress Report:   
 
To date, there are no published data using sodium fluorescein for the resection of central nervous 
system (CNS) tumors in children. Our group has considerable experience with the use of sodium 
fluorescein in adult tumors [19-20].  
 
The neurosurgeons at Children’s Hospital Colorado have extensive experience with pediatric brain 
and spine tumor surgery. They perform approximately 100 tumor surgeries each year, making them 
one of the busiest groups in the country. Their relevant research experience is formidable, having 
published 25 research articles related to brain and spine tumors in the last two years alone. Two of 
these papers were specifically about the use of sodium fluorescein in guiding adult brain tumor 
resections. 
 
 
IV. Research Methods 
 
A.  Outcome Measure(s):   
 
The primary outcome measure will be extent of tumor resection. For all patients, pre-operative 
imaging and post-operative imaging will be used to analyze the extent of resection of the 
tumors.  In intracranial lesions, the use of volumetric imaging tools will be used to calculate the 
extent of tumor resection. In spinal lesions, manual measurement will be used to determine the 
extent of resection.  
 
Secondary outcome measures include the subjective utility of fluorescein per the operating 
surgeon, as well as positive predictive value, sensitivity and specificity for extent of tumor 
resection. Additional outcome measure(s) will vary depending on the neurosurgical tumor 
removed. Intraoperative videos and images will be collected from the surgical case. Images 
obtained will be correlated to tissue biopsy and will aid in the analysis of fluorescein 


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extravasation in pediatric neurosurgical tumors. All tissue samples collected will be taken for 
histopathological analysis.  
 
B. Description of Population to be Enrolled:   
 
Potential study participants include patients between 31 days and 21 years old, who are being 
seen at Children’s Hospital Colorado for a central nervous system tumor (brain and spine 
tumor) and are undergoing neurosurgical resection. Enrollment will include 2 subsequent 
phases with the following tumor types in each phase:  
 
 
First Phase of Study:  
 High Grade Glioma 
 Pilocytic Astrocytoma  
 
 
Second Phase of Study:  
 Medulloblastoma 
 Ependymoma  
 Contrast Enhancing Spinal Tumors  
 
Inclusion Criteria: 
 
Age 31 days through 21 years on date of surgery 
 
Undergoing resection of a central nervous system tumor at Children’s Hospital 
Colorado 
 
Parent/legal guardian (or adult subject) willing and able to complete the informed 
consent process 
 
Exclusion Criteria: 
 
Tumor in functionally eloquent cortex that precludes maximal surgical resection 
 
Severe renal dysfunction 
 
Preoperative serum creatinine level > than normal range and GFR < 30. 
 
Severe liver dysfunction 
 
History of asthma or pulmonary spasm 
 
Known allergy to sodium fluorescein or any other contrast dye 
 
Previous administration of sodium fluorescein within the last 72 hours 
 
Pregnant or nursing mother 
 
Other unspecified reasons that, in the opinion of the investigator, make the subject 
unsuitable for enrollment. 
 
Tumors with primary differential diagnosis not included in the inclusion groups 
 
C. Study Design and Research Methods   
 
Study Design:  
 
This study will be a prospective non-randomized cohort study with patients presenting to 
Children’s Hospital Colorado for resection of a central nervous system tumor.  Due to 
heterogeneity of the pediatric central nervous system tumors and the evidence available, we 
will have a planned initial cohort (first phase) that will include tumor pathology that will allow us 
to test the feasibility of the study and the preliminary activity of fluorescein in the pediatric 
population. After completion of this initial cohort, we will expand our study to include tumors 
that are more specific to the pediatric population. 
 
Currently, there exist many tumor types where there is robust literature on the use of 
fluorescein [3,4,6-15,21-26,27-29]. We plan to enroll patients based on a phased system and 
after completion of the first phase, we will perform a safety analysis as outlined below.  


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After safety analysis is completed, we will either proceed to the next phase, or in the event 
there is a safety concern, the DSMC will terminate our study. Terms for termination are 
detailed below.  
 
Enrollment of ten patients is planned for each tumor type in each of the phases. The phases 
are designed to assess patients where evidence is available and proceed to tumor types where 
pediatric evidence is limited and the tumors are more unique to the pediatric population. This 
will allow us to safely assess patients and allow us to expand our trial in a controlled fashion.  
After completion of each phase of enrollment, we will continue enrolling the prior phase 
patients for a maximal total of 10 patients per each pathology group. Thus, maximal enrollment 
will be 20 patients for the first phase pathologies and 30 patients for the second phase 
pathologies, for a total enrollment of 50 treated patients and 150 historical controls 
 
 
First Phase of Study:  
 High Grade Glioma 
 Pilocytic Astrocytoma  
 
 
Second Phase of Study:  
 Medulloblastoma 
 Ependymoma  
 Contrast Enhancing Spinal Tumors  
 
 
Study Drugs and Devices: 
 
This study will employ the use of sodium fluorescein and an FDA approved operative 
microscope equipped with excitation and barrier filters for monitoring with sufficient fluorescent 
enhancement and contrast. Fluorescein sodium is a small organic salt with a molecular weight 
of 376 and excitation maximum at 494 nm and emission maximum at 521 nm. When injected 
intravenously, sodium fluorescein has a urine clearance of 24-72 hours. This agent 
accumulates in areas of diminished blood-brain barrier integrity and allows for determination of 
the margins between tumor and normal brain parenchyma [13].   
 
Schedule of Events: 
 
Table 1: Schedule of Events 
Preop 
Assessment
Surgery and  
Postop Inpatient Stay
Outpatient 
Follow-Up
Visit Type 
(Standard of Care) 
Neurosurgery 
Visit/Consult/H&P
Day of 
Surgery 
Prior to 
Discharge 
1Follow-Up 
Visit(s) 
Discharge 
through 
Month 2
Informed Consent/Assent 
X 
 
 
 
Eligibility Assessment 
X 
 
 
 
∆Demographics 
X 
 
 
 
∆Medical History 
X 
 
 
 
∆Neurologic Exam 
X 
 
X 
X 
∆Medical Exam 
X 
 
X 
X 
∆Imaging (MRI/CT) of the brain and/or 
Spine 
X 
 
X 
X 
∆Serum Creatinine 
X 
 
 
 
∆Pregnancy Test 
X 
 
 
 
Sodium Fluorescein Administration 
 
X 
 
 


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∆Tumor Resection Surgery 
 
X 
 
 
∆Intraoperative 
Photography/Videography 
 
X 
 
 
∆Tumor Biopsy/Pathology 
 
X 
 
 
Adverse Events 
 
X 
X 
X 
∆Standard of care procedures, data will be collected via chart review. 
1See Follow Up section below for more detail 
 
Research Methods:  
 
Study Recruitment: The primary neurosurgeons who will perform the resections will be 
investigators on the study and will identify eligible patients from their established practice. At 
the time surgical intervention is recommended, they will inform patients and parents/guardians 
of the existence of the study. Only those subjects with a clinical relationship with the study 
investigators will be recruited.  
 
Informed Consent and Assent: Patients (and parents/guardians of child patients) will be 
informed of the risks and possible benefits of the study, and informed consent will be obtained 
before any research procedures are initiated. Those who are interested in participating in the 
study will be informed of the study details by a member of the research team. Ample time will 
be provided to answer any questions and concerns regarding the study during the consenting 
process and patients will be given the option to take the consent form home to review. 
Additionally, patients will be provided with contact information in the event that questions 
should arise. Patients who undergo emergent surgery in which there is not sufficient time to 
obtain informed consent will be excluded from the study. In children 7-17 years, informed 
assent will also be obtained. Patients 18 years and older will consent for themselves. 
 
Eligibility Assessment: All inclusion/exclusion factors that result from procedures (imaging or 
laboratory tests) will already be clinically documented as part of the standard of care, so will be 
evaluated via chart review for the study. There are no study-specific screening tests or 
screening procedures.  
 
The exclusion criteria “preoperative serum creatinine level > normal range and GFR < 30” will 
be evaluated through chart review (creatinine level is included in standard of care preoperative 
lab results). The reference ranges used by Children’s Hospital Colorado’s clinical lab will be 
used to determine the normal range based on the patient’s age and gender. If a patient’s 
serum creatinine is greater than the normal range, GFR will be calculated using the following 
equation. If the GFR is < 30, the patient will be excluded. 
 
 
 
Table 2: GFR Calculation 
Serum Creatinine Reference Range 
Calculation for GFR 
Age
Normal Range
31 to 364 Days 
0.14 to 0.52 mg/dL 
1 to 10 Years 
0.23 to 0.61 mg/dL 
11 to 17 Years 
0.42 to 0.90 mg/dL 
Female: 18 to 21 Years 
0.52 to 0.99 mg/dL 
Male: 18 to 21 Years 
0.71 to 1.18 mg/dL 
𝐺𝐹𝑅= 
0.41 ∗𝐻𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑐𝑚
𝑆𝑒𝑟𝑢𝑚 𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑑𝐿 
 
The exclusion criteria “pregnant or nursing mother” will be evaluated for females of 
childbearing potential. We will utilize Children’s Hospital Colorado’s perioperative definition of 
childbearing potential as females who have reached menarche or are 12 years of age or older. 
Pregnancy testing is standard of care for these patients and pregnancy test results will be 
evaluated through chart review.  
 


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Pre-operative Evaluation: A standard of care neurosurgical assessment will occur at 
admission: standard clinical evaluation for tumor including pertinent history, physical and 
neurologic exam data, laboratory findings, and initial imaging studies will all be documented 
clinically and recorded via chart review for the study. 
 
Imaging: Patients will have pre- and post-operative imaging in accordance with the standard 
clinical procedures at Children’s Hospital Colorado. Patients in this study will not require any 
study-specific imaging outside the standard of care. All post-operative images are reviewed by 
fellowship trained pediatric specific neuroradiologists. Neuroradiologists are not informed on 
the administration of sodium fluorescein and will conduct review of the post-operative imaging 
per standard protocol. No imaging evidence of sodium fluorescein is visible on post-operative 
MR or CT imaging and the independent neuroradiologist is blinded to the operative course of 
the patient. 
 
Sodium Fluorescein Administration: Patients enrolled in this study will receive 3 mg/kg sodium 
fluorescein following induction of anesthesia by administration into a peripheral venous line 
over 10 seconds. This dose has been previously reported for use in a pediatric population and 
has been studied in adult tumor population [15]. Previous studies have used doses ranging 
from 500mg standing to 20mg/kg with minimal side effects [7]. The FDA-approved dosage for 
children is 7.7 mg/kg intravenously. A lower dose and earlier administration reduces the 
incidence of fluorescent contamination of normal brain. Furthermore, the advent of new 
neurosurgical microscopes with fluorescein filters decreases the dosage required to observe 
fluorescence.  
 
Tumor Resection: Resection of the lesions will proceed as normal as if sodium fluorescein had 
never been given. Resection will proceed with the use of a surgical microscope equipped with 
excitation and barrier filters for monitoring with sufficient fluorescent enhancement and 
contrast. The surgeon will be capable of switching the filters so as to observe the ordinary 
microscopic image and the fluorescein image as necessary. This ensures that the safety and 
normal operating procedure are minimally disturbed during this study.  
 
Fluorescein absorbs at a peak between 465-490 nm which is selected for from the light source 
by the excitation filter. The barrier filter will only permit fluorescence emitted by sodium 
fluorescein in the 500-530 nm range to the surgeon’s eye. The margins of resection will be 
based on identifying the fluorescein stained tissue that indicates neoplastic change and 
breakdown of the blood brain barrier. The resection will be performed piece by piece until the 
primary surgeon feels that surgical goal is achieved. Samples of fluorescent tissue will be sent 
to pathology for evaluation of histology.  
 
Utilizing the microscope’s internal recording device, we will record or photograph the surgery. 
When possible, biopsy location will be marked on the patient’s preoperative MRI with the 
neurosurgical navigation device and a screenshot of this localization will be taken from the 
device system. This will only be possible for intracranial lesion and will not be used for spinal 
lesions. Images will be stored on a password-protected encrypted computer on the Children’s 
Hospital Colorado server and accessible only to the investigators. Biopsies will be sent to 
pathology for diagnosis as is customary in all tumor resections, and diagnosis will be followed 
up in the patient’s medical record by authorized study personnel. Fluorescein staining will be 
correlated with biopsies/pathological samples based on samples collected per standard of 
care. Official pathology reports will be used to determine pathological correlations with 
fluorescein staining. 
 
Follow-Up: A neurosurgical assessment will occur post-operatively prior to discharge, as well 
as at standard of care outpatient follow-up clinic visits that take place between discharge and 
Month 2 post-surgery. These clinic visits typically occur at one week (for incision check) and 
one month post- surgery. Standard clinical evaluation for tumor includes pertinent history, 


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physical, neurologic exam data, and may also include laboratory findings and post-operative 
imaging studies. These will all be documented clinically and recorded via chart review for the 
study. Patients will be followed for the study through Month 2 (or 8 weeks) post-surgery.  
 
Furthermore, any adverse events occurring after surgery will be collected until 7 (for non-
serious AEs) or 30 days (for SAEs) after the last day of study intervention (administration of 
fluorescein). All adverse events will be followed for outcome information until resolution or 
through Month 6 post-surgery. 
 
For example, if a patient has no adverse events following surgery, they will only be followed 
through end of study period which is 2 months post-surgery. If the patient had adverse events 
within the first 30 days, those adverse events will be followed through resolution or 6 months 
post procedure, whichever comes first.  
 
Re-Enrollment: Patients who have previously been enrolled in this study and received prior 
administration of fluorescein sodium as a part of this study for guided tumor resection are 
eligible for re-enrollment into the study, should further surgical resection be clinically indicated. 
Patients will receive the same dosage as outlined in the protocol of 3mg/kg. Clearance of 
500mg of fluorescein sodium is 24-72 hours after administration of a single dose [16]. Patients 
re-enrolled into the study will be eligible after 3 days given the clearance time necessary for 
fluorescein sodium. Patients will be enrolled with the same study number. Patients will be re-
consented at time of re-enrollment. 
 
 
 
D.   Description, Risks and Justification of Procedures and Data Collection Tools: 
 
 
Potential Risks: Studies have examined the risk of using fluorescein for multiple purposes with 
no serious side effects [21]. The FDA has already approved the use of sodium fluorescein in 
adults and children for diagnostic angiography of the retina and it is also widely used as a 
contrast agent. The dose and route of administration being used in this study are consistent 
with the FDA approval for use of this drug in children.  
 
The use of intravenous sodium fluorescein in gastrointestinal procedures has been reported to 
be extremely safe. Side effects from these studies include nausea/vomiting, injection site 
erythema, rash, and epigastric pain. Other investigators have examined the safety profile of 
intravenous fluorescein use in angiography. In these studies, reported potential side effects of 
sodium fluorescein administration include, urticaria, syncope, respiratory reactions, cardiac 
reactions, and hypersensitivity reactions. Multiple mechanisms have been suggested such as 
vasovagal phenomenon, histamine release via a nonallergic pathway, and sympathetic 
discharge related to anxiety as the pathogenetic basis of these side effects. The most common 
symptoms (>20%) reported in these studies include malaise, headache, dizziness, and 
nausea/vomiting [22-24].  
 
A reported side effect of Fluorescein is yellowish skin for 6-12 hours after administration and 
yellow urine for 24-36 hours after administration. Fluorescein is systemically cleared by 48 to 
72 hours after administration. 
 
The package insert for Fluorescein describes “care must be taken to avoid extravasation 
during injection as the high pH of fluorescein solution can result in severe local tissue damage.” 
To alleviate this risk, the medication will be given IV push over 10 seconds. 
 
Confidentiality of Study Data: Data including enrollment, study drug orders, pre-operative and 
postoperative exams and adverse event reporting will remain identifiable. De- identification of 
this information is not possible as patient identifying information is necessary for continued 


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patient safety monitoring and follow-up while in the trial.  
 
Data that is collected clinically and analyzed for this study will remain identifiable in the 
patient’s medical record but will be de-identified in the research records. Identifying information 
will be replaced with a unique study-specific code. All documents will be handled in accordance 
with the HIPPA policy and the Children’s Hospital Colorado “Research Data – Ownership, Use, 
and Retention” policy. Only members of the research team will have access to the study 
documents and they will be stored on a password protected, encrypted computer on the secure 
Children’s Hospital Colorado server. Paper documents will be stored in a locked filing cabinet 
in the secure administration pavilion at Children’s Hospital Colorado. 
 
Privacy Protections: Every effort will be made to protect patient privacy. Patients enrolling in 
the study will be informed with whom their information will be shared and they will sign a 
combined consent/HIPAA authorization form. Patients will not be identified if the study results 
are published or presented at a scientific meeting. 
 
E.   Potential Scientific Problems:   
 
One possible limitation of this study is the single-institution nature of the project. Because 
Children’s Hospital Colorado is a high-volume center, we are confident that we will be able to 
enroll the number of subjects needed for successful data analysis. Once this pilot project is 
complete, one of the future directions will be to conduct a multi-site study that can account for 
inter-institutional variance. 
 
Another possible limitation is the absence of randomization to a control arm. We plan to use 
resection rates reported in the literature, as well as historical controls from our institution to 
compare to tumor resection rates during this pilot study.  
 
F.   Data Analysis Plan:   
 
Annually at the Children’s Hospital of Colorado, roughly 80 patients present with tumors 
requiring neurosurgical interventions. Prior adult population studies had enrolled between 10 – 
40 patients. Importantly, these studies have largely involved single tumor types. Our study 
involves multiple tumor types and locations and would warrant increased enrollment for 
statistical analysis. Additionally, extent of surgical resection is an important outcome in our 
project. Using data extrapolated from adult studies, such as the most recent Niera et al. study, 
32 patients were enrolled and compared to historical controls for tumor resection. This study 
demonstrated differences in extent of resection. Given the population and nature of our study, 
about 1/10 of the patients whom qualify for this study will be spine patients and the rest will be 
cranial with varying types of tumor pathology. [19] 
 
Furthermore, if we use the number from this study [Niera] patients with fluorescein use had an 
average resection rate of 93.1% versus 77.1% for non-fluorescein historical control patients 
[19] Power calculations using a one-way ANOVA with alpha=0.05 power at 70%, 80%, and 
90%, a mean difference of 16% (93.1-77.1) and a standard deviation of 25% are shown in 
Table 3.  
 
Table 3: Power Calculation
Power 
N Total 
70% 
64 
80% 
80 
90% 
106 
 
 


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Our pediatric neurosurgery/ neuro-oncology program benefits from a robust tumor program 
with multiple historical patients with reliable clinical follow-up that assesses for post-operative 
neurologic reactions. However, we do not believe that randomization is feasible in our study. 
The overall prevalence of pediatric brain tumors and the nature of the pathology would not 
allow our center the ability to perform a randomized trial in a meaningful time-frame. Our trial is 
designed to be a multi-year trial and randomization would double the study time for enrollment 
and greatly decrease feasibility to perform this study.  
 
Given this, we propose a 3:1 ratio of historical controls to fluorescein treated patients to match 
tumor location and histology. 150 historical controls will be pulled from the last ten years of 
Children’s Hospital patients and matched to the 50 fluorescein treated cases on lesion location 
and pathology. This 3:1 ratio will strengthen our ability to objectively assess for adverse events 
related to sodium fluorescein as well as our extent of tumor resection analysis. Importantly, 
historical controls undergo stereotactic-guided tumor resection in a similar fashion to patients 
undergoing fluorescein administrations as outlined in our protocol.  
 
All patients who undergo sodium fluorescein-aided resection will also have neuropathological 
analysis. We will analyze correlation of fluorescein staining to histopathology. Tissue obtained 
during the time of surgery will be used to correlate fluorescein staining to histopathological 
diagnosis. This data will be used to calculate sensitivity and specificity of fluorescein staining 
for tumors. Pre- and post-operative imaging will be used to assess the degree of the extent of 
resection in intraparenchymal tumors. Data collected from post-operative follow-up will be used 
to assess for potential complications/adverse reactions associated with sodium fluorescein 
administration. 
 
For data analysis, extent of tumor resection will be compared as a continuous value across 
groups using a parametric ANOVA.  Further calculations, such as sensitivity, specificity and 
positive predictive value will be calculated by contingency tables.  Additionally, since group 
membership is not random we will run an adjusted analysis predicting the likelihood of tumor 
resection as a continuous outcome adjusting for demographic and co-morbidity factors.  
Significance will be assigned at p < 0.05. 
 
Furthermore, adverse reactions and population/demographic data will be characterized using 
relative risk and odds ratios. Overall survival and progression free survival analysis will be 
characterized using Kaplan-Meier curves and compared across groups using a log rank test. 
 
G. Adverse Events and Unanticipated Problems: 
 
1. Adverse Events and Serious Adverse Events 
 
a. Definition of Roles: 
 
Sponsor: person listed in field 1 of form FDA 1571 
 
Site Principal Investigator: person listed in field 1 on form FDA 1572 
 
Licensed Independent Practitioner (LIP): MD with current Colorado Medical License 
 
b. Definition of Adverse Events (AE) 
Adverse event means any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related (21 CFR 312.32 (a)) 
 
c. Definition of Serious Adverse Events (SAE) 
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of 
either the Site Principal Investigator or Sponsor, it results in any of the following outcomes:  
 
death, 
 
a life-threatening adverse event, 


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 
inpatient hospitalization or prolongation of existing hospitalization, 
 
a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or 
 
a congenital anomaly/birth defect. 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical 
judgment, they may jeopardize the participant and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  
 
d. Classification of an Adverse Event 
i. Severity of Event: 
A study team member, who is a Licensed Independent Provider (LIP) will be responsible for 
determining the severity of each AE. 
 
For adverse events (AEs), the following guidelines will be used to describe severity: 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s 
daily activities.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
• 
Severe – Events interrupt a participant’s usual daily activity and may require systemic drug 
therapy or other treatment. Severe events are usually potentially life-threatening or 
incapacitating.  Of note, the term “severe” does not necessarily equate to “serious”.] 
 
ii. Relationship to Study Intervention: 
A study team member, who is a Licensed Independent Provider (LIP) will be responsible for 
determining the relationship of each AE to the study intervention. 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event, including an abnormal 
laboratory test result, occurs in a plausible time relationship to study intervention 
administration and cannot be explained by concurrent disease or other drugs or chemicals. 
The response to withdrawal of the study intervention (dechallenge) should be clinically 
plausible. The event must be pharmacologically or phenomenologically definitive, with use 
of a satisfactory rechallenge procedure if necessary. 
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence 
of other factors is unlikely. The clinical event, including an abnormal laboratory test result, 
occurs within a reasonable time after administration of the study intervention, is unlikely to 
be attributed to concurrent disease or other drugs or chemicals, and follows a clinically 
reasonable response on withdrawal (dechallenge). Rechallenge information is not required 
to fulfill this definition. 
• 
Potentially Related – There is some evidence to suggest a causal relationship (e.g., the 
event occurred within a reasonable time after administration of the trial medication). 
However, other factors may have contributed to the event (e.g., the participant’s clinical 
condition, other concomitant events). Although an AE may rate only as “possibly related” 
soon after discovery, it can be flagged as requiring more information and later be upgraded 
to “probably related” or “definitely related”, or downgraded to …, as appropriate. 
• 
Unlikely to be related – A clinical event, including an abnormal laboratory test result, 
whose temporal relationship to study intervention administration makes a causal 
relationship improbable (e.g., the event did not occur within a reasonable time after 
administration of the study intervention) and in which other drugs or chemicals or 
underlying disease provides plausible explanations (e.g., the participant’s clinical condition, 
other concomitant treatments). 
• 
Not Related – The AE is completely independent of study intervention administration, 
and/or evidence exists that the event is definitely related to another etiology. There must 
be an alternative, definitive etiology documented by the  


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iii. Expectedness: 
A study team member, who is a Licensed Independent Provider (LIP) will be responsible for 
determining whether an AE is expected or unexpected. 
An AE will be considered unexpected if the nature, severity, or frequency of the event is not consistent with 
the risk information previously described for the study intervention. 
 
e. Time Period and Frequency for Event Assessment and Follow Up 
21 CFR 312.64(b) requires that the Site Principal Investigator records non-serious adverse events 
and reports them to the Sponsor according to the timetable for reporting specified in the protocol.  
A properly delegated study team member will record all adverse events with start dates occurring 
any time after administration of fluorescein until 7 (for non-serious AEs) or 30 days (for SAEs) after 
the last day of study intervention. All events will be followed for outcome information until resolution 
or stabilization or through Month 6 post-surgery. 
 
All AEs occurring while on study will be documented regardless of their relationship to the study 
intervention, and whether or not they meet the definition of an SAE. AEs will be captured, reviewed 
and assessed by an LIP member of the study team. The outcome of this review and assessment 
will be documented by a properly delegated study team member on an Adverse Event Log. 
Information to be collected includes event description, time of onset (start date) and time of 
resolution/stabilization of the event (end date), and the LIP’s assessment of expectedness, severity 
and relationship to study intervention.  
 
Any medical condition that is present at the time the participant is screened will be considered as 
baseline medical history, and will not be recorded as an AE. However, if the study participant’s 
condition deteriorates at any time during the study, the event will be recorded as an AE.  
 
Changes in the severity or frequency of an AE will be documented as separate events to allow an 
assessment of the duration of the event at each level of severity or frequency.  
 
AEs characterized as intermittent will be documented with onset and duration of each episode. 
 
At each study visit, a properly delegated study team member will document all occurrences of AEs 
and SAEs since the last visit. This information will be gathered through direct observation (e.g. 
rash), elicited from or spontaneously volunteered by the participant, documentation in Medical 
Records, laboratory or other clinical reports or notes, or identified in patient-reported outcome tools 
(e.g. diaries, surveys, questionnaires), or any other means. 
 
f. 
Adverse Event Reporting 
Adverse Event Reporting will be performed in accordance with the study protocol, any contractual 
agreement, and all IRB requirements.  
21 CFR 312.64(b) requires that the Site Principal Investigator records non-serious adverse events 
and reports them to the Sponsor according to the timetable for reporting specified below. 
Disease-Related Events (DREs): The following disease-related events (DREs) are expected and 
common with brain tumor surgery, and will not be reported per the standard process for adverse 
event reporting: bleeding in the brain,  injury or swelling to the brain, infection in the brain or at 
wound site, meningitis, seizures, hydrocephalus, cerebral spinal fluid leakage, the need for 


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additional surgery, tearing of the eyes, damage to the eye, blood clots, stroke, dizzy spells, 
recurrence or tumor growth, postoperative pain and allergic reactions to anesthesia. 
AEs will be reported as follows (check the arrangement to be used for this protocol): 
i. 
To Safety Monitoring entity: 
☐  Study Principal Investigator is an LIP and provides safety oversight 
 
Review of AEs and SAEs will be conducted in regularly occurring research team 
meetings that at scheduled at pre-determined frequency. The review and any follow-up 
action will be documented in meeting minutes.  
☐  Safety Officer/Monitor is an LIP and provides safety oversight 
 
Review of AEs and SAEs will be conducted at predetermined intervals in accordance 
with the Safety Monitoring Plan developed for this study 
 
Safety officer/monitor may be independent or part of study team, as appropriate to risk 
and phase of study 
☒ Data Safety Monitoring Board/Committee (DSMB/C)  
 
Review of AEs and SAEs will be conducted in accordance with the DSMB Charter and 
Data Safety Monitoring Plan developed for this study 
ii. 
To IRB: 
 
Within 5 days of becoming aware of them, a properly delegated study team member will report to 
the IRB any AE that meets the definition of an unanticipated problem (UAP), which means the 
event is are unexpected, related to the research procedures, and caused harm or risk of harm.  
 
SAEs that do not meet the criteria for prompt reporting will be tabulated on an aggregate reporting 
form for submission at the time of continuing review.  
Note: If there is an independent safety monitor for the study (e.g., Safety Officer, DMC, or 
DSMB), aggregate reports do not need to be submitted at the time of continuing review. 
Instead, a summary report from the monitor should be submitted at the time of continuing 
review. 
 
iii. 
To FDA: 
A narrative or tabular summary showing the most frequent and most serious adverse events by 
body system will be provided by the Sponsor to the FDA with each annual report in compliance 
with 21 CFR 312.33(b)(1). 
 
g. Serious Adverse Event Reporting 
 
The Site Principal Investigator will immediately report to the Sponsor any serious adverse event, 
whether or not considered study intervention related, including those listed in the protocol or 
investigator brochure, and will include the study team LIP’s assessment of whether there is a 
reasonable possibility that the study intervention caused the event.  
 
Study endpoints that are serious adverse events (e.g. all-cause mortality) will be reported in 
accordance with the protocol unless there is evidence suggesting a causal relationship between 


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the study intervention and the event (e.g., death from anaphylaxis). In that case, the Site Principal 
Investigator must immediately report the event to the Sponsor. 
 
All SAEs will be followed until satisfactory resolution or until the study team’s LIP deems the event 
to be chronic or the participant is stable.  
 
Serious adverse events that are considered related (i.e., determined to be possibly, probably, or 
definitely related) to the investigational product by the Sponsor will be followed until the event 
resolves or stabilizes. Any SAE that occurs after treatment completion, and is considered by the 
Sponsor to be related to the investigational product, will be documented and reported as 
appropriate. 
 
i. 
To FDA: 
 
The Sponsor is responsible for notifying the Food and Drug Administration (FDA). Events meeting 
the following criteria will be submitted to the FDA as expedited IND Safety Reports according to the 
following guidance and timelines: 
 
7 Calendar Day Telephone or Fax Report 
The Sponsor will notify the appropriate review division at the FDA of any fatal or life-threatening 
adverse event that is unexpected and assessed by the Sponsor to be possibly related to the use of 
the investigational product. An unexpected adverse event is one that is not already described in the 
investigational product’s Investigator Brochure. Such reports are to be telephoned or faxed to the 
appropriate review division at FDA and to the manufacturer of the investigational product within 7 
calendar days of first learning of the event. 
 
The report will be completed using Form FDA 3500A (Mandatory Reporting). 
 
15 Calendar Day Written Report 
The Sponsor will notify the appropriate review division at the FDA, in a written IND Safety Report, 
of any serious, unexpected AE that is considered reasonably or possibly related to the use of the 
investigational product. An unexpected adverse event is one that is not already described in the 
investigational product’s investigator brochure. 
 
Written IND Safety reports will include an Analysis of Similar Events in accordance with regulation 
21 CFR § 312.32. All safety reports previously filed by the Sponsor with the IND concerning similar 
events will be analyzed and the significance of the new report in light of the previous, similar 
reports commented on. 
 
Written IND safety reports with Analysis of Similar Events will be submitted to the appropriate 
review division at the FDA, and the manufacturer of the investigational product within 15 calendar 
days of first learning of the event, using Form FDA 3500A. 
 
Written IND Safety Reports will be submitted to the IRB(s) of record in accordance with IRB 
Guidelines. 
 
IND Annual Reports 
The Sponsor will provide annual reports to the appropriate review division at the FDA within 60 
days of the IND’s anniversary date, until the IND is withdrawn or terminated. 
 
ii. 
To Safety Monitoring entity: 


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SAEs will be reported to the safety monitoring entity at the next scheduled research team meeting 
or as defined in the Safety Monitoring Plan, which ever applies to this study. 
 
 
2. Unanticipated Problems 
a. Definition of Unanticipated Problems (UAP) 
 
An unanticipated problem involving risk to participants or others includes any incident, experience, 
or outcome that meets all of the following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been 
caused by the procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
b. Unanticipated Problem Reporting 
 
The Site Principal Investigator will report unanticipated problems (UAPs) to the reviewing 
Institutional Review Board (IRB) per IRB policy.  
 
c. Reporting Unanticipated Problems to Participants 
Any event which may relate to subjects’ willingness to continue participation will be provided to the 
subjects, per IRB policy.  
 
 
H. Data and Safety Monitoring 
The PI will be responsible for monitoring the trial, in addition to overseeing the safety and efficacy 
of the trial, executing the DSM plan and complying with all reporting requirements to the local and 
federal authorities. This oversight will be accomplished through additional oversight from the Data 
and Safety Monitoring Committee (DSMC) at the University of Colorado Cancer Center (CU 
Cancer Center).   
The DSMC is responsible for ensuring data quality and patient safety for all clinical studies at the 
CU Cancer Center. A summary of the DSMC’s activities is as follows: 
 
Conduct internal audits 
 
Ongoing review of all serious adverse events (SAEs), unanticipated problems 
(UAPs) and reportable adverse events (AEs) 
 
Has the authority to close and/or suspend trials for safety or trial conduct 
issues 
 
 May submit recommendations for corrective actions to the CU Cancer 
Center’s Executive Committee 
All SAEs, UAPs and reportable AEs are to be reported to the DSMC within 5 business days of 
receiving notification of the occurrence.   


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The PI will provide a DSM report to the CU Cancer Center DSMC on a 6-month basis. The DSM 
report will include a protocol summary; current numbers; summary of toxicity data to include 
specific SAEs, UAPs and AEs; any dose modifications; all protocol deviations; and protocol 
amendments. Results and recommendations from the review of this 6-month report by the DSMC 
will then be submitted by CHCO to COMIRB at continuing review.  
Study audits conducted by the DSMC will consist of a review of the regulatory documents, consent 
forms, and source data verification.  Documentation of the audit conducted by the DSMC will then 
need to be submitted to the IRB of record at the time of the IRB’s continuing review of this trial.  
Importantly, the DSMC is composed of personnel that includes persons with specialty training in 
pediatric oncology and pediatric surgery. The DSMC at our institution routinely monitors both adult 
and pediatric trails at our institution. The oversight of our study will include normal DSMC activities 
with an additional specific review of our study after the first phase of enrollment to evaluate the 
safety of our study. DSMC approval will be obtained prior to proceeding to the second enrollment 
phase of enrollment. 
Study Stopping Criteria 
The objective of the safety review is to decide whether the study should continue per protocol, 
proceed with caution, be further investigated, be discontinued, or be modified and then proceed. 
Suspension of enrollment is a potential outcome of the safety review. 
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party (DSMC) to the PI, funding 
agency, and regulatory authorities. If the study is prematurely terminated or suspended, the PI will 
promptly inform the IRB and will provide the reason(s) for the termination or suspension. 
Circumstances that may warrant termination or suspension include, but are not limited to: 
 
Determination of unexpected, significant, or unacceptable risk to participants defined by 
reporting of AEs, SAEs and UAPs 
 
Insufficient compliance to protocol requirements 
 
Data that are not sufficiently complete and/or evaluable 
 
Determination of futility 
 
Study closure based on PI decision or sponsor/funder decision 
The study may resume once concerns about safety, protocol compliance, data quality are 
addressed and satisfy the sponsor, IRB and/or FDA. 
 
I.  Summarize Knowledge to be Gained:   
 
Sodium fluorescein for intraoperative neuronavigation using a neurosurgical microscope has been 
useful in the resection of adult nervous system tumors. Currently, there are no studies researching 
sodium fluorescein in pediatric brain and spine tumors. The application of this technology has the 
potential to: increase the fidelity of tumor tissue identification, increase potential to achieve safe 
maximal resection, and increase overall survival and prognosis in brain and spine tumor patients.  
 
 
 


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 J. References: 
 
1. Sanai N, Berger M. Glioma extent of resection and its impact on patient outcome. Neurosurg, 
2008 Apr;62(4):753-64; discussion 264-6. doi: 10.1227/01.neu.0000318159.21731.cf. PMID: 
18496181. 
2. Stummer, W. et al. Extent of resection and survival in glioblastoma multiforme: identification of 
and adjustment for bias. Neurosurg, 2008. 62(3): p. 564-76; discussion 564-76. 
3. Moore, G. Fluorescein as an agent in the differentiation of normal and malignant tissues. 
Science, 1947. 106: p. 130-131. 
4. Moore, GE et al. The Clinical Use of Fluorescein in Neurosurgery. Journal of Neurosurgery, 
1948. 5(4): p. 392-398. 
5. Moore GE, P.W. The clinical use of fluorescein in neurosurgery; the localization of brain tumors. 
Journal of Neurosurgery, 1948. 5(4): p. 392-298. 
6. Kuroiwa, T., Y. Kajimoto, and T. Ohta. Development of a Fluorescein Operative Microscope for 
use During Malignant Glioma Surgery. Surgical Neurology, 1998. 50(1): p. 41-49. 
7. Jun Shinoda, et al. Fluorescence-guided resection of glioblastoma multiforme by using high-
dose fluorescein sodium. Journal of Neurosurgery, 2003. 99(3): p. 597-603. 
8. Koc, K., et al. Fluorescein sodium-guided surgery in glioblastoma multiforme: a prospective 
evaluation. Br J Neurosurg, 2008. 22(1): p. 99-103. 
9.  Acerbi, F., et al. Fluorescein-guided surgery for grade IV gliomas with a dedicated filter on the 
surgical microscope: preliminary results in 12 cases. Acta Neurochir (Wien), 2013. 155(7): p. 1277-
86. 
10. Schebesch, K.M. et al. Sodium fluorescein-guided resection under the YELLOW 560 nm 
surgical microscope filter in malignant brain tumor surgery--a feasibility study. Acta Neurochir 
(Wien), 2013. 155(4): p. 693-9. 
11. da Silva, C.E., V.D. da Silva, and J.L. da Silva. Sodium fluorescein in skull base meningiomas: 
a technical note. Clin Neurol Neurosurg, 2014. 120: p. 32-5. 
12. Rey-Dios, R., E.M. Hattab, and A.A. Cohen-Gadol. Use of intraoperative fluorescein sodium 
fluorescence to improve the accuracy of tissue diagnosis during stereotactic needle biopsy of high-
grade gliomas. Acta Neurochir (Wien), 2014. 156(6): p. 1071-5; discussion 1075. 
13. Diaz, R.J., et al. Study of the biodistribution of fluorescein in glioma-infiltrated mouse brain and 
histopathological correlation of intraoperative findings in high-grade gliomas resected under 
fluorescein fluorescence guidance. J Neurosurg, 2015: p. 1-10. 
14. Okuda T, Kataoka K, Yabuuchi T, Yugami H, Kato A. Fluorescence-guided surgery of 
metastatic brain tumors using fluorescein sodium. Journal of clinical neuroscience, 2010 : official 
journal of the Neurosurgical Society of Australasia 17:118-121. doi:10.1016/j.jocn.2009.06.033 
15. Ung, T.H., et al. The use of fluorescein sodium in the biopsy and gross-total resection of a 
tectal plate glioma. J Neurosurg Pediatr, 2015. 16(6): p. 732-5. 
16. Alcon, I. Fluorescite - fluorescein sodium injection, solution, A. Labratories, Editor. 2011. 
17. Ung TH RL, Nevzati E, Harasaki Y, Witt JP, Ormond DR, Lillehei OK, and Finn M. 
Intraoperative sodium fluorescein for tissue biopsy and resection of spinal cord lesions. 2018.  
18. Ung TH RLNE, Harasaki Y, Witt JP, Ormond DR, Lillehei OK, and Finn M. Intraoperative 
sodium fluorescein for tissue biopsy and resection of spinal cord lesions. 2018. 
19. Neira JA, Ung TH, Sims Js, Malone HR, Chow DS, Samanamud JL, Zanazzi GJ, Guo X, 
Bowden SG, Zhao B, Sheth SA, McKhann GM 2nd, Sisti MB, Canoll P, D’Amico RS, Bruce JN. 
Aggressive resection at the infiltrative margins of glioblastoma facilitated by intraoperative 
fluorescein guidance. Journal of Neurosurgery, 2017. 127(1): p.111-122. 
20. Bowden SG, Neira Ja, Gill BJA, Ung TH, Englander ZK, Zanazzi G, Chang PD, Samanamud J, 
Grinband J, Sheth SA, McKhann GM 2nd, Sisti MB, Canoll P, D’Amico RS, Bruce JN. Sodium 
Fluorescein Facilitates Guided Sampling of Diagnostic Tumor Tissue in nonenhancing Gliomas. 
Neurosurgery, 2017. [Epub ahead of print] 
21. Wallace, M.B., et al. The safety of intravenous fluorescein for confocal laser endomicroscopy in 
the gastrointestinal tract. Aliment Pharmacol Ther, 2010. 31(5): p. 548-52. 
22. Balbino, M., G. Silva, and G.C.T.P. Correia. Anafilaxia com convulsões após angiografia com 
fluoresceína em paciente ambulatorial. Einstein (São Paulo), 2012. 10(3): p. 374-376. 


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23. Bearelly, S., S. Rao, and S. Fekrat. Anaphylaxis following intravenous fluorescein angiography 
in a vitreoretinal clinic: report of 4 cases. Can J Ophthalmol, 2009. 44(4): p. 444-5. 
24. Dilek, O., A. Ihsan, and H. Tulay. Anaphylactic reaction after fluorescein sodium administration 
during intracranial surgery. J Clin Neurosci, 2011. 18(3): p. 430-1. 
25. Fluorescite® (fluorescein sodium injection, solution) [package insert]. Alcon Laboratories, Inc., 
Fort Worth, Teas; 2009. 
26. Ung TH, Kellner C, Neira JA, Wang SH, D'Amico R, Faust PL, Canoll P, Feldstein NA, Bruce 
JN. The use of fluorescein sodium in the biopsy and gross-total resection of a tectal plate glioma. J 
Neurosurg Pediatr, 2015. 16:732-735. doi:10.3171/2015.5.PEDS15142 
27. Wallace MB, Meining A, Canto MI, Fockens P, Miehlke S, Roesch T, Lightdale CJ, Pohl H, 
Carr-Locke D, Lohr M, Coron E, Filoche B, Giovannini M, Moreau J, Schmidt C, Kiesslich R.The 
safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract. 
Aliment Pharmacol Ther, 2010, 31:548-552. doi:10.1111/j.1365-2036.2009.04207.x 
28. Xue Z, Kong L, Pan CC, Wu Z, Zhang JT, Zhang LW. Fluorescein-Guided Surgery for Pediatric 
Brainstem Gliomas: Preliminary Study and Technical Notes. J Neurol Surg, 2018. B Skull Base 
79:S340-S346. doi:10.1055/s-0038-1660847 
29. Zhang J, Al-Nahari F, Wang ZF, Lin FH, Zhao YY, Xiao SY, Liu JM, Ke C, Chen ZH, Jiang Y, 
Yang M, Sai K, Wang J, Mou YG. Application of fluorescein sodium in the resection of vermis 
pilocytic astrocytomas. World J Surg Oncol, 2017; 15:46. doi:10.1186/s12957-017-1108-5 
 
 


Assent Form Template
CF-016, Effective 8-22-2018
Person in Charge of the Study: Todd Hankinson, MD, MBA
COMIRB No: 18-0242
Version Date: March, 29, 2021
Assent Form for: Sodium Fluorescein-Guided Resection of Pediatric 
Neurosurgical Tumors 
What is this study about?
You are being asked if you want to be in this research study.  The goal of this study is to 
use a fluorescent dye called sodium fluorescein to help doctors see the tumor better 
during surgery. 
Why are you asking me?
You are being asked to be in the study because you have brain tumor or a spine tumor.
What Do I Have to Do or What Will Happen to Me?
If you are in the study, you will be asked to: 

Have sodium fluorescein dye put through your IV while your asleep for surgery

Allow the study doctor to video record and take pictures of your surgery

Allow study staff to look at your medical records and images

Allow a microscope company called Leica Microsystems to look at your video and 
images from surgery
The study will last for 2 months. The only time you will get the dye is during surgery.
You don’t have to answer any questions that you don’t want to, and you can stop at any 
time.
Will this Hurt?
The dye will be put through your IV while you are asleep for surgery. There will not be 
extra pokes for this study. Everything else will be part of your normal surgery care.
If you are in the study, you could have: 

Your skin and urine turn yellow

A funny taste in your mouth

Pain in your stomach and throwing up

Pain in your head

Dizziness

Itchy or red skin
These things do not usually happen, but you could have:

A skin injury where your IV was

An allergic reaction

Passing out

Heart problems

Unusual body movements
COMIRB
APPROVED
For Use
11-Jun-2021
10-Jun-2022


Assent Form Template
CF-016, Effective 8-22-2018

Blood clots

Lung problems

Death
Can I ask Questions?
You can ask any questions that you have now about the study.
If you have a question later, you can ask and get an answer.  If you want to, you can 
call Todd Hankinson at (720)-777-2985.
Do I Have to Do This?
You do not have to be in this study. No one will be mad at you if you say no. You can 
choose to stop at any time. Just tell the researcher if you want to stop. 
Do you want to be in the study at this time? (Check one box)
   Yes
   No
You will get a copy of this form to keep.
Child’s Signature:
  Date: 
Child’s Printed Name:
_____
Consent form explained by: 
_____________________
(Print name)
I have explained the research at a level that is understandable by the child and believe 
that the child understands what is expected during this study.
Signature of Person Obtaining Assent: _________________________________ 
Date: ____________