Conditions: Bone Cancer Chondrosarcoma Ewing's Sarcoma Osteosarcoma Rhabdomyosarcoma Bone Necrosis Bone Sarcoma Osteomyelitis
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 32
Healthy volunteers: no

Brief summary:
This pilot trial studies the differentiation of bone sarcomas and osteomyelitis with ferumoxytol-enhanced magnetic resonance imaging (MRI). Imaging procedures that allow doctors to more accurately differentiate between malignant bone sarcomas and osteomyelitis may help in diagnosing patients correctly and may result in more timely treatment.

Detailed description:
BACKGROUND; In this study, T1, T2, and T2\* represent parameters of magnetic resonance imaging (MRI).

The T1 relaxation time, also known as the spin-lattice relaxation time, is a measure of how quickly the net magnetization vector (NMV) recovers to its ground state in the direction of B0. T1 is assessed immediately post-contrast. A T1-weighted image (T1WI ) is one of the basic pulse sequences in MRI and demonstrates differences in the T1 relaxation times of tissues. A T1WI relies upon the longitudinal relaxation of a tissue's net magnetization vector (NMV).

T2 is a time constant for the decay of transverse magnetization arising from natural interactions at the atomic or molecular levels, and be considered the "natural" or "true" T2 of the tissue. However, in any nuclear magnetic resonance (NMR) experiment, transverse magnetization decays much faster than would be predicted by natural atomic and molecular mechanisms. Accordingly, T2 \* is the time constant for the decay of transverse magnetization as observed in a tissue during a MRI scan, and be considered the"effective T2" (represented as T2\*). T2\* is always ≤ T2. In this study, T2 \* is assessed after 24 hours.

OUTLINE:

Patients receive ferumoxytol intravenously (IV) and then undergo ferumoxytol-enhanced MRI up to 1 hour after infusion and up to 24 hours post-infusion.

PRIMARY OBJECTIVES:

* Establish magnetic resonance (MR) imaging characteristics of bone sarcomas and osteomyelitis based on their ferumoxytol-enhancement on relatively early post-contrast T1-weighted images.
* Establish MR imaging characteristics of bone sarcomas and osteomyelitis based on their ferumoxytol-enhancement on delayed postcontrast T2-weighted images.
* Establish T2-weighted MR imaging characteristics of iron-labeled mesenchymal stem cell (MSC) in osteonecrotic bone over time, before and after surgical core decompression and bone marrow implantation.
* Adding a second branch for patients who can not receive ferumoxytol but still getting the MRI exam. These patients will server as controls.

Arms:
arm 1: Intravenous injection of Feraheme, 5 mg Fe/kg

Interventions: intervention 1: Feraheme intervention 2: Magnetic Resonance Imaging (MRI) scan
Intervention descriptions: intervention 1: 5 mg/kg by intravenous (IV) administration intervention 2: Standard of Care magnetic resonance imaging (MRI) scans using GE 1.5T and 3T MRI scanners/

Protocol document:
Prot_SAP_000.pdf: 
 
TITLE: DIFFRENTIATION OF BONE SARCOMA AND OSTEOMYELITIS WITH 
FERUMOXYTOL-ENHANCED MRI 
 
Coordinating Center 
Stanford Cancer Center 
875 Blake Wilbur Drive 
Stanford, CA 94305 
 
Protocol Director: 
Dr.Heike Daldrup-Link 
725 Welch Road, Rm 1679, MC 5913 
Stanford, CA 94305-5654 
Telephone: E-mail address: heiked@stanford.edu 
 
Co-Investigators 
Dr. Neyssa Maria Marina 
Department of Pediatrics-Hematology/oncology 
1000 Welch Road, Suite 300 
Palo Alto, California 94604-1812 
Telephone 
Fax:  
 
Biostatistician 
Dr. Alex McMillan 
Health Research and Policy 
Redwood Building  
Rm T160A 
Stanford, CA  
Biostatistics MC 5405 
Telephone 
Study Coordinator 
Jennifer Vancil (Research Administrator ) 
Dr. Rakhee Gawande (Research Fellow) 
Lucile Packard Children’s Hospital 
Radiology, MC 5913 
725 Welch Road, Rm 1681 
Stanford, CA 94305-5913 
TelephoneFax:  
 
SRC Approved Protocol / Version # 1/ Version Date: 4/04/2011 
 
NCT01336803 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 2 of 33 
TABLE OF CONTENTS 
 
*Please include page numbers for each section below 
 
 
Page 
PROTOCOL SYNOPSIS ................................................................................................................3 
SCHEMA .........................................................................................................................................4 
LIST OF ABBREVIATIONS ..........................................................................................................5 
 
1. OBJECTIVES ............................................................................................................................6 
2. BACKGROUND ................................................................................................................. 7-12 
3. PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES .......................... 13-14 
4. TREATMENT PLAN ........................................................................................................ 15-17 
5. INVESTIGATIONAL AGENT/DEVICE/PROCEDURE INFORMATION ................... 18-19 
6. DOSING DELAYS/DOSE MODIFICATIONS ............................................................... 20-21 
7. ADVERSE EVENTS AND REPORTING PROCEDURES ...................................................22 
8. STUDY CALENDAR .............................................................................................................23 
9. MEASUREMENT ...................................................................................................................24 
10. REGULATORY CONSIDERATIONS ...................................................................................25 
11. STATISTICAL CONSIDERATIONS.....................................................................................26 
 
REFERENCES ........................................................................................................................ 27-29 
 
APPENDICES 
A. Participant Eligibility Checklist 
B. Case Report Forms 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 3 of 33 
 
PROTOCOL SYNOPSIS 
 
In the table below summarize the basic aspects of this research. This is to be used as a quick reference guide. 
Remove any section that is not relevant to the research.  
 
TITLE 
DIFFRENTIATION OF BONE SARCOMA 
AND 
OSTEOMYELITIS 
WITH 
FERUMOXYTOL-ENHANCED MRI 
STUDY PHASE 
Pilot 
INDICATION 
Pediatric patients of 10-21 years of age with 
bone sarcoma or osteomyelitis 
INVESTIGATIONAL 
PRODUCT 
OR 
PROCEDURE 
Diagnostic MRI with intravenous contrast 
agent Ferumoxytol (off label use of FDA 
approved iron compound Ferumoxytol). 
PRIMARY OBJECTVE 
Establish MR imaging characteristics of bone 
sarcomas and osteomyelitis based on their 
ferumoxytol-enhancement on relatively early 
and delayed post-contrast MR images 
TREATMENT SUMMARY 
Single Intravenous injection of MR contrast 
agent Ferumoxytol, administered during the 
initial MR exam 
SAMPLE SIZE  
20 
STATISTICAL CONSIDERATIONS 
Descriptive 
statistics 
will 
be 
used 
to 
characterize contrast enhancement; the key 
estimates will be the standard deviation and the 
coefficient of variation.  The area under the 
ROC curve will be calculated as a measure of 
separation 
and 
the 
significance 
of 
the 
separation will be assessed using the Wilcoxon 
rank sum test. 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 4 of 33 
 
SCHEMA 
 
Provide an outline of the trial in graphical form.  Show essential inclusion criteria, major decision branches 
(including randomization/stratification) and the primary outcome.  
 
 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 5 of 33 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
Include additional abbreviations as needed.  Remove any unnecessary abbreviations. 
 
AE 
Adverse event 
CI 
Confidence interval 
CKD 
Chronic renal disease 
CRF 
Case report/Record form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CT 
Computed Tomography 
ECG 
Electrocardiogram 
Gd 
Gadolinium 
GI 
Gastrointestinal 
IRB 
Institutional Review Board 
IV 
Intravenous 
MRI 
Magnetic resonance Imaging  
PET 
Positron emission tomography 
SAE 
Serious adverse event 
USPIO 
Ultra small superparamagnetic iron oxide 
VE-MRI 
Vascular enhanced MRI 
WHO 
World Health Organization 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 6 of 33 
 
1. OBJECTIVES 
 
1.1. 
Primary Objective  
 
The differentiation between malignant bone sarcomas, especially Ewing sarcomas, and a subacute osteomyelitis 
can be difficult based on imaging tests (1-4). Biopsy, curettage and/or cultures of the lesion may be necessary to 
establish a diagnosis. These procedures are invasive and time-consuming, causing delay in treatment and 
significant anxiety of the patients and their parents. The goal of our project is to establish a novel, non-
invasive, immediately clinically applicable imaging test for the differentiation of bone sarcomas and 
osteomyelitis. Our approach relies on the FDA-approved iron supplement drug ferumoxytol (Feraheme), which 
is used in patients for intravenous treatment of iron deficiency (5-8). Ferumoxytol is composed of iron oxide 
nanoparticles, which provide a strong T1- and T2-signal on magnetic resonance (MR) images and, thus, can be 
used as an MR contrast agent (9, 10). We hypothesize, that MR images after intravenous injection of 
ferumoxytol will demonstrate a significantly stronger T1- and T2-enhancement of osteomyelitis when compared 
to malignant bone sarcomas. The T1-effect of ferumoxytol is dependent on its ability to interact with protons in 
the target tissue (9, 14, and 21). Thus, we expect to find a significantly stronger T1-enhancement of edematous 
inflammations as opposed to highly cellular tumors. In addition, ferumoxytol is phagocytosed by local 
macrophages, which leads to a persistent MR signal defect on 24 h delayed T2-weighted MR images (9). Thus, 
we expect to find a significantly stronger T2-enhancement of macrophage-rich inflammations as opposed to 
bone sarcomas with relatively few tumor-associated macrophages in their stroma.  
We will investigate the following specific aims: 
   
1) Establish MR imaging characteristics of bone sarcomas and osteomyelitis based on their ferumoxytol-
enhancement on relatively early postcontrast T1-weighted images. 
2) Establish MR imaging characteristics of bone sarcomas and osteomyelitis based on their ferumoxytol-
enhancement on delayed postcontrast T2-weighted images. 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 7 of 33 
 
2. BACKGROUND 
 
2.1  
 Study Disease 
 
Sarcomas arise from transformed mesoderm (connective tissue which forms bone, cartilage, and soft tissues) 
and represent approximately 5-10 % of adult and childhood tumors (1, 25). Bone sarcomas, such as 
osteosarcomas and Ewing sarcomas, occur in approximately 650 new cases annually in children and adolescents 
(cancernetwork.com). The patients typically present with pain and/or a palpable swelling of the extremities or 
the bones of the pelvis. An accurate diagnosis is essential in order to refer these patients to appropriate 
treatment by oncologists and orthopedic surgeons. However, conventional clinical, laboratory and imaging 
signs of bone sarcomas, especially Ewing sarcomas, can show significant overlap with a subacute osteomyelitis 
(2-4). On conventional radiographs or CT scans, a Ewing’s sarcoma and an osteomyelitis may present as an ill 
defined, lytic diaphyseal lesion that aggressively destroys the bone, often with an onion-skin or sunburst pattern 
periosteal reaction. MRI is currently the clinical standard technique to further evaluate the extent of either a 
sarcoma or an osteomyelitis, but has also demonstrated significant overlap between the imaging signs of these 
two pathologies (26, 27). Bone scans and PET scans show overlap between these two entities as well (28,29). 
As a result, there are numerous reports of misdiagnoses of sarcomas as inflammations with inappropriate 
antibiotic treatment leading to tumor progression or inadequate biopsies leading to limb amputation (30-33). 
Thus, more accurate diagnostic techniques that can reliably differentiate these different pathologies are critically 
needed. We propose to utilize differences in the cellular composition of sarcomas and inflammations to generate 
a more specific diagnostic test. Interestingly, 99mTc sulphur colloid, which is phagocytosed by macrophages, 
demonstrated a marked uptake in osteomyelitis, but not malignant tumors, supporting our concept (34, 41, and 
42). Sulphur colloid scans are associated with considerable radiation exposure and low anatomical resolution, 
thereby limiting its utility in children. Ultra small superparamagnetic iron oxide nanoparticles (USPIO) provide 
a radiation free alternative to sulphur colloid and can be depicted with MR imaging, which provides 3D 
information, high soft tissue contrast and sub-millimeter anatomical resolution. We and others have utilized 
preclinical USPIO compounds for MR imaging of inflammations and tumors (9, 11, 13, 14, 19, 20, and 35). 
However, to the best of our knowledge, the value of FDA-approved USPIO for the differentiation of malignant 
bone sarcomas and osteomyelitis has not been investigated. 
 
2.2  
Study Agent/Device/Procedure 
 
Study Agent: 
Ferumoxytol (Feraheme) represents a novel USPIO compound that has been recently FDA-approved for 
intravenous treatment of iron deficiencies in patients with renal failure (6).  
Indication and Usage: Ferumoxytol is used as an iron replacement product indicated for the treatment of iron 
deficiency anemia in adult patients with chronic kidney disease. 
We propose an off label application of ferumoxytol as a MRI contrast agent. 
Mechanism of Action: Ferumoxytol consists of a superparamagnetic iron oxide that is coated with a 
carbohydrate shell, which helps to isolate the bioactive iron from plasma components until the iron-
carbohydrate complex enters the reticuloendothelial system macrophages of the liver, spleen and bone marrow. 
The iron is released from the iron-carbohydrate complex within vesicles in the macrophages. Iron then either 
enters the intracellular storage iron pool (e.g., ferritin) or is transferred to plasma transferrin for transport to 
erythroid precursor cells for incorporation into hemoglobin. 
Animal Studies: Animal studies demonstrate that the plasma half-life of ferumoxytol increased with increasing 
dose. The highest tissue concentration of ferumoxytol was found in the liver, spleen and central lymphnode 
pool. Studies with radio-labeled drug product demonstrated that the renal elimination of iron in ferumoxytol 
was insignificant, while the carbohydrate coating was significantly excreted in urine and feces. Repeat dose 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 8 of 33 
toxicity studies of ferumoxytol in rats and dogs demonstrated dose dependent decreases in body weight gain and 
food consumption, and increases in pigmentation intensity. No systemic toxicity or immunotoxicity was 
observed at relevant clinical doses. 
Clinical Studies: The safety and efficacy of ferumoxytol for the episodic treatment of iron deficiency anemia in 
patients with CKD were assessed in three randomized, open-label, controlled clinical trials. 
Ferumoxytol is not currently approved for diagnostic imaging applications. It is being evaluated as an agent for 
vascular enhanced MRI (VE-MRI). In August 2008 the FDA granted Fast track designation to ferumoxytol for 
its development as a diagnostic agent for VE-MRI to improve assessment of peripheral arterial disease in 
patients with known or suspected chronic renal disease (CKD). The fast track process is designed to facilitate 
the development and expedite the FDA’s review of products.  
Clinical Pharmacokinetics: Ferumoxytol exhibits dose-dependent, capacity-limited elimination from plasma 
with a half life of approximately 15 hours in humans. 
Major route of elimination: Ferumoxytol is slowly cleared from blood by tissue macrophages (liver, spleen, 
lymph node and active bone marrow) over 2-3 months. The macrophages release the iron to body iron stores 
where it can be incorporated into hemoglobin. 
Drug Interactions: Ferumoxytol may reduce the absorption of concomitantly administered oral iron 
preparations. 
 
Study Device: MR Scanner, 1.5T and 3 T, GE healthcare. MRI with and without contrast is a non-significant 
risk exam, as defined by the FDA and IRB guidelines. 
 
For clinicaltrials.gov compliance: 
Ferumoxytol has been approved by The FDA for the treatment of iron deficiency anemia in adult patients with 
chronic kidney disease. 
We propose an off label use of an FDA approved iron compound Ferumoxytol (contrast agent) for pediatric 
patients. 
  
2.3  
Rationale 
 
Realization of our goal to develop an immediately clinically applicable MR imaging test for non-invasive 
differentiation of osteomyelitis and bone sarcomas will enable us to provide a quick and non-invasive diagnosis 
of these pathologies, accelerate patient referral to appropriate pediatric subspecialities and prevent inappropriate 
anti-inflammatory treatment or delay of cytotoxic treatment of sarcomas. Accelerated specific therapy of these 
very different pathologies based on a more accurate diagnostic test may ultimately improve and accelerate 
positive treatment-outcomes, reduce hospitalizations and reduce associated direct and indirect costs to our 
society. Since ferumoxytol is safe in patients with renal insufficiency and not associated with any risk of 
nephrogenic sclerosis (6), it can be used as an alternative contrast agent to gadolinium chelates in patients with 
renal insufficiency or in patients in whom creatinine lab values are not or not yet available. This aspect might be 
particularly significant for patients with a suspected osteomyelitis, in whom urgent MR scans may be needed 
and evaluation of serum creatinine values would delay imaging diagnosis and treatment. 
The current alternative diagnostic methods are: biopsy, which is invasive, painful, and frequently inadequate; 
MRI, with significant overlap/difficulty in distinguishing between the two entities without an iron nanoparticle 
contrast; PET/CT/X-ray, which are even more difficult to distinguish and include exposure to ionizing radiation. 
The current standard of imaging is an MRI; the addition of an iron nanoparticle contrast agent is expected to 
make this a much more efficacious diagnostic tool. No standard treatment will be withheld, and the standard of 
care diagnostic test is included in our research. 
 
   
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 9 of 33 
   2.4      Study Design 
Diagnostic: The goal of our project is to establish a novel, non-invasive, immediately clinically applicable 
imaging test for the differentiation of bone sarcomas (osteosarcomas and Ewing sarcomas) and osteomyelitis. 
Our approach relies on the FDA-approved iron supplement drug ferumoxytol (Feraheme), which is used in 
patients for intravenous treatment of iron deficiency. Ferumoxytol is composed of iron oxide nanoparticles, 
which provide a strong T1- and T2-signal on magnetic resonance (MR) images and, thus, can be used as an MR 
contrast agent. Based on our extensive experience with pre-clinical and clinical imaging applications of iron 
oxide nanoparticles, we hypothesize that MR image after intravenous injection of ferumoxytol will demonstrate 
a significantly stronger T1- and T2- enhancement of osteomyelitis when compared to malignant bone sarcomas. 
Hypotheses:  
(1) Bone sarcomas and osteomyelitis show a different T1-enhancement at 1 h post injection (p.i.) of 
ferumoxytol 
(2) Bone sarcomas and osteomyelitis demonstrate differences in T2-enhancement at 24 h p.i. of ferumoxytol 
We plan to enroll 20 patients in this study, 10 patients with bone sarcomas and 10 patients with an 
osteomyelitis. The sample size has been determined based on our preliminary data and power calculations. We 
will screen all patients with proven or suspected bone sarcoma or osteomyelitis for potential participation in this 
study. Inclusion criteria will comprise an age of 10-21 years (we do not include younger patients in order to 
exclude need of sedation) and a suspected or confirmed diagnosis of a bone sarcoma or osteomyelitis. Exclusion 
criteria comprise MR-incompatible metal implants, need of sedation (since an anesthesia is not supported by 
this), claustrophobia or hemosiderosis/hemochromatosis. All patients will undergo two subsequent imaging 
tests on a 3T MR scanner, using dedicated surface coils for high resolution MR imaging. During the first MR 
examination, ferumoxytol will be injected intravenously at a dose of 5 mg Fe/kg:  
 
(A) MRI before and up to 1 h after injection of ferumoxytol for evaluation of lesion perfusion, blood volume, 
microvascular permeability and interstitial retention (enhanced permeability and retention effect of 
macromolecules) 
(B) 24h after (A): Follow up MRI for evaluation of macrophage phagocytosis 
 
The following pulse sequences will be applied: Long axis T1-spin echo (SE) images and short TI inversion 
recovery (STIR) images, covering the whole bone from joint to joint, axial T2-weighted fat-saturated fast spin 
echo (FSE) images focusing on the bone lesion, dynamic contrast-enhanced T1-weighted 3D spoiled gradient 
recalled echo (SPGR) images, and axial multi-echo T2*-weighted gradient echo (GE) images. The pulse and 
blood pressure of the patients will be measured before and after each MR exam and the patients and parents will 
be asked for any objective or subjective adverse events.  
 
 Interventional model:  Parallel 
 Single Blind  
 Nonrandomized study 
 Primary outcome: Efficacy. 
Primary outcome of these examinations is to define distinctive MR signal characteristics of bone   
                        sarcomas and osteomyelitis, which will be immediately applicable in a clinical setting. 
 
2.5 
Correlative Studies Background 
 
Our group has worked on MR imaging techniques with iron oxide nanoparticles since 1995 (11-24). We and 
others have found that intravenously injected USPIO with diameters in the order of 20-50 nm cause a long 
lasting, positive “blood pool” or vascular enhancement on T1-weighted MR images (9,14,19). In pathologies 
with an increased microvascular permeability, USPIO extravasate into the interstitium and cause a T1-effect of 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 10 of 33 
the target tissue, which is strongly dependent on the proton content of the interstitial space (among other 
technical factors). We have thoroughly investigated various factors that lead to an optimized tissue T1-
enhancement of USPIO (9, 14, and 19). We have shown that malignant lesions in the bone marrow of patients 
show nearly no USPIO T1-enhancement, presumably due to their high cellularity, small intercellular space and 
low proton content (Fig. 1). Inflammations, on the other hand, show a strong T1-enhancement, presumably due 
to the edematous, proton rich environment (Fig. 2). These data suggest that tumors and inflammations may 
demonstrate differences in T1-enhancement. 
USPIO in the interstitium are subsequently slowly phagocytosed by macrophages in various target tissues, such 
as liver, spleen, bone marrow or macrophage containing pathologies, where they primarily cause a negative 
(dark) signal effect on T2-weighted MR images (11,13,18,19,24). Focal malignant tumor lesions in organs of 
the RES (reticulo-endothelial system) contain no or very few macrophages, thus do not phagocytose USPIO, 
and stand out as bright lesions (Fig. 1). However, macrophage rich inflammations cause a marked signal loss on 
delayed T2-weighted MR images (Fig. 2). Thus, we have evidence from a variety of pre-clinical and clinical 
investigations, that tumors and inflammations may show distinct T2-enhancement patterns. 
Of note, the PI of this proposed study has applied USPIO as MR contrast agents in phase II and III clinical trials 
in adult patients (11, 13, 14, and 20). These contrast agents are very well tolerated and show excellent safety 
profiles (5-8). The delivered iron dose via a typical ferumoxytol administration is in the order of 150-500 mg 
iron oxides (note that these are coated iron particles, not free iron), which is equivalent to or lower than the iron 
dose administered with one blood sample. USPIO are slowly metabolized in the liver and not excreted via the 
kidneys. Thus, they are safe to use in patients with renal insufficiencies and are not associated with any risk of 
nephrogenic sclerosis (a potential adverse event after injections of certain gadolinium chelates). Anaphylaxis or 
anaphylactoid reactions were reported in 0.2% of a subject, which is in the order of or lower compared to other 
MR contrast agents (see FDA report, ref. 6). 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 11 of 33 
 
Figure 1: MR signal characteristics of bone marrow tumors with USPIO, as demonstrated in a patient with Non-
Hodgkin’s lymphoma after chemotherapy and GCSF therapy. (A) T1-weighted MR images before contrast 
media administration show a hypercellular reconverted bone marrow, which demonstrates diffusely decreased 
signal due to its high cellularity. Two focal lesions are noted (arrows). (B) T1-weighted MR images after 
intravenous administration of the USPIO ferumoxtran-10 (Sinerem / Combidex) do not show any T1-
enhancement (positive contrast) of these lesions. (C) Precontrast STIR images show a relatively high signal of 
the hypercellular reconverted bone marrow with focal, more hyperintense lesions (arrows). (D) STIR images 
after intravenous administration of ferumoxtran-10 show a marked, diffuse T2-enhancement (negative contrast, 
signal loss) of the normal bone marrow due to phagocytosis of the agent by macrophages in normal bone 
marrow. Focal neoplastic lesions (arrows) contain no or few macrophages and stand our as bright lesions 
(arrows). 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 12 of 33 
 
Figure 2: MR signal characteristics of inflammation following intravenous injection of the USPIO ferumoxtran-
10 in a rat model of antigen-induced arthritis of the knee joint. (A) A precontrast T1-weighted MR scan shows a 
swollen knee joint. (B) An early post-contrast T1-weighted scan demonstrates marked T1-enhancement of the 
inflamed joint (arrow). (C) On delayed MR images, the T1-contrast has diminished. (D) Precontrast T2-
weighted scan. (E) Early postcontrast T2-scans demonstrate negative perfusion effect of the inflamed synovium 
(arrow). (F) Delayed T2-weighted MR scans demonstrate persistent T2-contrast enhancement of the synovium 
(compare D). (G) AN H&H stain of a sagittal histologic slice through the knee joint show massive inflammation 
of the synovium with thickening and cellular infiltration. (H) Antidextran stains of the arthritic synovium (100-
fold magnification) show positive contrast agent particles mostly in the interstitium at 2 hours p.i. (I) and 
exclusively within macrophages (arrows) at 24 hours p.i. As can be seen from these images, USPIO exert both 
T1- and t2-effect when the nanoparticles are located extracellular. USPIO exert T2-effects only and loose their 
T1-effect when they are phagocytosed and located intracellulary. 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 13 of 33 
 
3. PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
 
Refer to the Participant Eligibility Checklist in Appendix A.  
 
3.1  
Inclusion Criteria 
 
3.1.1 Inclusion criteria will comprise: 
            a) An age of 10-21 yrs 
            b) Suspected or confirmed diagnosis of a bone sarcoma or osteomyelitis. 
 
3.1.2 We do not include younger patients (age less than 10 yrs) in order to exclude need of 
sedation. There will be no gender/race-ethnic restrictions 
 
                 3.1.3      In this pediatric & adult study, the participant or parent/guardian is consented,   
                               and the patient when a minor is given an assent form and involved in the discussion as  
                               appropriate. 
 
3.2  
Exclusion Criteria 
    
                  3.2.1    Exclusion criteria will comprise: 
                              a)  Contraindication to MRI  
                              b)  Presence of metal implants 
                              c)  Need for sedation or anesthesia 
                              d)  Claustrophobia 
                              e)  Hemosiderosis/hemochromatosis 
 
3.2.2 There will be no restrictions regarding use of other Investigational Agents. 
 
3.2.3 Patients with evidence of iron overload, hemosiderosis/hemochromatosis will be excluded. 
 
3.2.4  History of allergic reactions to similar compounds will be obtained and patients with 
positive history of allergic reactions will be excluded from the study. 
 
3.2.5 Pregnancy or nursing patients will be excluded from the study. A pregnancy test will be done 
prior to the MR examination for postmenarchal teenage girls, in whom pregnancy may be 
possible. Only patients with a negative pregnancy test will be included in the study. 
 
3.3       Informed Consent Process 
 
All participants or parents/guardians will be provided a consent form describing the study with 
sufficient information for participants or parents/guardians to make an informed decision regarding 
their participation.  Participants or parents/guardians will sign the IRB approved informed consent 
prior to participation in any study specific procedure. The participant or parents/guardians will 
receive a copy of the signed and dated consent document.  The original signed copy of the consent 
document will be retained in the medical record or research file.  
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 14 of 33 
3.4       Randomization Procedures 
 
This is a non-randomized study. 
 
 
 
3.5  
Study Timeline 
 
Anticipated Start Date: 4/1/2011 
Anticipated End Date: 4/1/2012 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 15 of 33 
4. TREATMENT PLAN 
 
STUDY PLAN: 
All potential participants will be patients seen through regular referral methods in Dr. Marina's clinic. During 
the course of a normal clinic visit, if Dr. Marina notes a patient who meets the inclusion/exclusion criteria, they 
will be offered an opportunity to enroll in the study.  
We will screen all patients with proven or suspected bone sarcoma or osteomyelitis for potential participation in 
this study.  
Following screening parameters will be recorded within 30 days prior to enrollment: 
i) Complete medical history 
ii)Physical Examination 
iii)Vital Signs 
iv) Height 
v) Weight 
iv) ECG 
Once enrolled, each participant will undergo an initial MRI without contrast and with ferumoxytol injection for 
anatomic detailing, and then another MRI without contrast (delayed imaging) 24 hours later to assess the 
metabolic reaction to the contrast agent (macrophage phagocytosis, the difference in how the two different 
diseases react to the contrast agent).  
Screening of the patient will take 15-30 minutes. Active participation involves two MRI scans for a total of 
approximately 2-3 hours. Data analysis will continue until publication in approximately 12 months from 
initiation of the study. 
Audio recording, video recording and photography will not be used. Tissue samples will not be retained. 
DRUG ADMINISTRATION: 
The study requires one intravenous injection of Feraheme during the first MRI scan for diagnostic purpose, at a 
dose of 5 mg Fe/kg. Considering a Ferumoxytol/Feraheme dose of 5 mg/kg and a concentration of 30 mg Fe/ml, 
we anticipate to inject 250-400 mg Fe in a teenager with an average body weight of 50-80 kg. This will translate 
into 8.3 – 13.3 ml volume of contrast agent to be injected. An M.D. will administer the contrast agent slowly via 
a hand injection, with continuous and direct feedback from the patient, over a time period of 1-2 minutes, i.e. 
with a maximum injection rate of 10 ml / min. According to continuous feedback from the patient during the 
contrast media administration, we will inject slower as deemed appropriate. 
Since ferumoxytol is a “blood pool agent” (i.e. providing long lasting vascular enhancement), it is not crucial 
for the quality of the imaging scan to administer the contrast agent while the patient is in the scanner or to start a 
post-contrast scan immediately after contrast media administration. Thus, we will hand-inject ferumoxytol 
slowly into a peripheral vein while the patient is outside of the MR scanner and under direct supervision. We 
will observe the patient for a few minutes, acquire vital signs and ask him/her for any subjective adverse effects 
before we continue the imaging scan. We will continue to observe the patient closely and record heart rate and 
respiratory rate continuously during the MR scan. Blood pressure and temperature will be monitored before, 
directly after contrast media injection as well as at the end of the MR scan. The patient will be monitored up to 
90 minutes after the contrast media administration. These data will be recorded according to the following table, 
which is part of the case report form: 
 
 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 16 of 33 
Patient Name: 
Patient weight: 
Birth Date: 
Ferumoxytol dose (5 mg/kg):  
Medical Record #: 
Ferumoxytol volume:  
= weight (kg) x dose (5 mg Fe/kg) / 30 mg 
Fe/ml 
Ferumoxytol injection, date (dd/mm/yyyy) and start time (hh/min): 
Ferumoxytol injection end time (hh/min): 
Planned injection rate: 10 ml / min 
Actual injection rate:  
Contrast agent completely injected: yes  / no Actual injection volume:  
Evidence of paravasal injection: yes / no 
Local Reaction at injection site: yes / no 
Vital signs: 
pre 
0 min 
15 min 30 min 45 min 60 min 
90 min 
Heart Rate 
 
 
 
 
 
 
 
Respiratory rate 
 
 
 
 
 
 
 
Blood pressure 
 
 
 
 
 
 
 
Temperature 
 
 
 
 
 
 
 
Any objective or subjective 
adverse reaction (time): 
 
 
 
 
 
 
 
Any objective or subjective 
adverse reaction (describe): 
 
 
 
 
The MR exam will be carried out in the Pediatric CT/MR Imaging facility at Lucile Packard Children’s 
Hospital or in the MR imaging suite at the Lucas Center. Both imaging facilities have resuscitation equipment 
for intervention in case of a rare, but possible event of an allergic contrast agent reaction. Oxygen supply, 
emergency medications, a “drug box” and CODE cart are available on both sites. A state licensed M.D will be 
present in the magnet suite during all contrast media injections. In addition, a pediatric nurse with special 
training in contrast agent interventions will be present in the imaging facility and available to assist with 
emergency interventions. The Emergency Department of Stanford Hospital is within walking distance to the 
imaging facilities. In case of serious AEs, physicians in the ED are also immediately available to help with 
emergency interventions. 
 
Warnings: i) Ferumoxytol may cause serious hypersensitivity reactions including anaphylaxis and/or 
anaphylactoid reactions. In clinical studies, serious hypersensitivity reactions were reported in 0.2% of subjects 
receiving Ferumoxytol. This frequency of hypersensitivity reactions is not higher compared to standard MR 
contrast agents, used for routine clinical MR scans. 
ii) Hypotension may follow Ferumoxytol administration. In clinical studies, hypotension was reported in 1.9 % 
of subjects. 
iii) Iron Overload. Ferumoxytol should not be administered in patients with iron overload. 
 
4.1  
General Concomitant Medication and Supportive Care Guidelines 
 
N/A. Our study is diagnostic only and will not limit the participants' treatment options or administration of 
concomitant medications or supportive care. 
 
4.2 
Criteria for Removal from Study 
 
Criteria for removal from study: 
 i) Incomplete MR images,  
 ii) Image artifacts 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 17 of 33 
 iii) Adverse reaction to contrast agent, 
 iv) Upon request of Patient for exclusion from study 
v) Suspected patients of bone sarcoma or osteomyelitis with incorrect assignment to a pathology.  
 
Patients removed from the study will be replaced in order to reach a total of 10 subjects for each pathology. 
 
 
4.3 
 Alternatives 
 
The current alternative diagnostic methods are: biopsy, which is invasive, painful, and frequently inadequate; 
MRI, with significant overlap/difficulty in distinguishing between the two entities without an iron nanoparticle 
contrast; PET/CT/X-ray, which are even more difficult to distinguish and include exposure to ionizing radiation. 
The current standard of imaging is an MRI, which is included in our study; the addition of an iron nanoparticle 
contrast agent is expected to make this a much more efficacious diagnostic tool. 
The conduct of our research should actually improve the speed with which the participants receive the most 
appropriate therapy, as we expect to be able to distinguish much more quickly between the differentials for the 
symptoms the patient’s experience. 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 18 of 33 
5. INVESTIGATIONAL AGENT/DEVICE/PROCEDURE INFORMATION 
 
 
5.1 
 Investigational Agent/Device/Procedure   
 
Study Agent: 
Ferumoxytol (Feraheme) represents a novel USPIO compound that has been recently FDA-approved for 
intravenous treatment of iron deficiencies in patients with renal failure (6). Ferumoxytol nanoparticles have a 
mean hydrodynamic diameter of 30 nm and are composed of an iron oxide core and a hydrophilic synthetic 
coating (6). Ferumoxytol exerts strong signal effects on MR images, as quantified by a high r1 relaxivity of 38 
L mmol-1 s-1 and a high r2 relativity of 83 L mmol-1 s-1 at 20 mHz (9). Ferumoxytol has been applied as a 
contrast agent for MR imaging of arthritis in an animal model (9) and imaging of glioblastomas in patients (10). 
To the best of our knowledge, ferumoxytol has not been investigated for MR imaging of bone sarcomas or 
osteomyelitis. In MR imaging Ferumoxytol shortens the relaxation times for nearby hydrogen atoms. This effect 
can be imaged with appropriate MR pulse sequences. 
Indication and Usage: Ferumoxytol is used as an iron replacement product indicated for the treatment of iron 
deficiency anemia in adult patients with chronic kidney disease. 
We propose an off label application of Feraheme as a MRI contrast agent. 
Mechanism of Action: Ferumoxytol consists of a superparamagnetic iron oxide that is coated with a 
carbohydrate shell, which helps to isolate the bioactive iron from plasma components until the iron-
carbohydrate complex enters the reticuloendothelial system macrophages of the liver, spleen and bone marrow. 
The iron is released from the iron-carbohydrate complex within vesicles in the macrophages. Iron then either 
enters the intracellular storage iron pool (e.g., ferritin) or is transferred to plasma transferrin for transport to 
erythroid precursor cells for incorporation into hemoglobin. In MR imaging Ferumoxytol shortens the 
relaxation times for nearby hydrogen atoms. This effect can be imaged with appropriate MR pulse sequences. 
Animal Studies: Animal studies demonstrate that the plasma half-life of Ferumoxytol increased with increasing 
dose. The highest tissue concentration of ferumoxytol was found in the liver, spleen and central lymphnode 
pool. Studies with radio-labeled drug product demonstrated that the renal elimination of iron in ferumoxytol 
was insignificant, while the carbohydrate coating was significantly excreted in urine and feces. Repeat dose 
toxicity studies of ferumoxytol in rats (cumulative exposure approximately 12 times the anticipated exposure of 
a human therapeutic course of 1.02 g of ferumoxytol on mg/m2 basis) and dogs (cumulative exposure 
approximately 40 times the anticipated exposure of a human therapeutic course of 1.02 g of ferumoxytol on 
mg/m2 basis) demonstrated dose dependent decreases in body weight gain and food consumption, and increases 
in pigmentation intensity. No systemic toxicity or immunotoxicity was observed at relevant clinical doses. 
Clinical Studies: The safety and efficacy of Ferumoxytol for the episodic treatment of iron deficiency anemia in 
patients with CKD were assessed in three randomized, open-label, controlled clinical trials. 
Ferumoxytol is not currently approved for diagnostic imaging applications. It is being evaluated as an agent for 
vascular enhanced MRI (VE-MRI). In August 2008 the FDA granted Fast track designation to ferumoxytol for 
its development as a diagnostic agent for VE-MRI to improve assessment of peripheral arterial disease in 
patients with known or suspected chronic renal disease (CKD). The fast track process is designed to facilitate 
the development and expedite the FDA’s review of products. AMAG-sponsored Phase I/IIa studies have been 
completed and results published (36, 37, 38, and 39). Doses of 0.4-2 mg/kg in normal volunteers demonstrated 
arterial and venous vessels in several body regions (36). VE-MRI effectively identified aortic root 
incompetence in 6 subjects (37). In another reported study, 11 subjects with a variety of vascular disease who 
were scheduled for clinically indicated angiography, doses 1 to 4 mg/kg (38). In this study ferumoxytol imaging 
was done using a variety of pulse sequences. The study confirmed the ability to perform imaging of different 
arterial segments. An additional publication showed promise in the evaluation of deep venous thrombosis (39). 
Several additional studies on vascular imaging of the cerebral and pelvic arterial circulations have been 
conducted under physician-sponsored investigational new drug applications. In a study of patients with central 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 19 of 33 
nervous system disease, Ferumoxytol in doses of 1 to 4 mg/kg was compared with non-contrast time-of-flight 
MRI, Gadolinium-enhanced MRI and VE-MRI (40). Ferumoxytol, with its persistence in vasculature due to its 
low vascular permeability and long intravascular half-life, provided better estimates of cerebral perfusion than 
gadolinium, and differences in biomarker properties were considered to be clinically advantageous in evaluating 
12 patients with malignant brain tumors (40). 
Clinical Pharmacokinetics: Ferumoxytol exhibits dose-dependent, capacity-limited elimination from plasma 
with a half life of approximately 15 hours in humans. 
Major route of elimination: Ferumoxytol is slowly cleared from blood by tissue macrophages (liver, spleen, 
lymph node and active bone marrow) over 2-3 months. The macrophages release the iron to body iron stores 
where it can be incorporated into hemoglobin. 
Drug Interactions: Ferumoxytol may reduce the absorption of concomitantly administered oral iron 
preparations. 
Adverse Reactions: The most common adverse reactions (≥2%) following administration of Ferumoxytol are 
diarrhea, nausea, dizziness, hypotension, constipation and peripheral edema. Ferumoxytol may cause serious 
hypersensitivity reactions including anaphylaxis and/or anaphylactoid reactions. In clinical studies, serious 
hypersensitivity reactions were reported in 0.2% of subjects receiving Ferumoxytol.  Hypotension may follow 
Ferumoxytol administration. In clinical studies, hypotension was reported in 1.9 % of subjects. 
Dose: Single intravenous injection of Ferumoxytol during the first MRI scan, at a dose of 5 mg Fe/kg. 
 The delivered iron dose via a typical ferumoxytol administration is in the order of 150-500 mg iron oxides 
(note that these are coated iron particles, not free iron), which is equivalent to or lower than the iron dose 
administered with one blood sample. 
 
Study Device:  
MR Scanner, 1.5T and 3 T, GE healthcare. MRI with and without contrast is a non-significant risk exam, as 
defined by the FDA and IRB guidelines. 
 
5.2 
 Availability 
 
                 The study drug will be purchased from AMAG, Manufacturer 
 
5.3 
 Agent Ordering 
 
                  The agent will be ordered by research administrator Jennifer Vancil. 
 
5.4 
 Agent Accountability 
 
                 The investigational drug will be kept secure and locked with Jennifer Vancil.  


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 20 of 33 
6. DOSE MODIFICATIONS 
 
Dose modification scheme: 
(A) Serious anaphylactoid reactions are not dose dependent. Thus, in case we should observe an increased 
incidence of severe anaphylactoid reactions, i.e. more than one patient in our limited study population of 
20 patients, or if any of our patients encounters a permanent impairment due to the ferumoxytol 
administration, the study will be terminated. 
 
(B) In case we should observe an unexpected decrease in blood pressure of more than 10% in more than one 
patient via blood pressure measurements or in case we observe severe nausea in more than one patient, 
we will successively decrease the administered dose by 1 mg/kg until event-free tolerance is achieved. 
Of note, our colleagues from Oregon Health & Science University (see below) reported no such side 
effects of ferumoxytol in their population of children with brain tumors. 
 
(C) Precontrast MR scans will serve as an internal standard. We will measure the signal intensity of 
sarcomas and osteomyelitis and divide this signal by the signal of normal muscle to normalize for 
potential MR spectrometer variations over time. We expect at least 20% tumor/muscle enhancement on 
post-contrast T2-weighted MR scans compared to precontrast scans. If this enhancement will not be 
achieved, but ferumoxytol is well tolerated, we will increase the administered dose to 6 mg Fe/kg with a 
maximum total amount of 510 mg Fe (FDA-approved dose for single injection). 
 
(D) In the unlikely event, that the T1- and T2-enhancement of both pathologies exceeds 500%, we have 
reached a plateau of contrast agent accumulation for both pathologies rather than depicting an expected 
relative limited accumulation of ferumoxytol in sarcomas compared to osteomyelitis. Based on our 
experience with pre-clinical and clinical iron oxide applications, we expect that maximal difference 
between sarcomas and osteomyelitis occur with the highest dose. This is the reason why we limit our 
study population to this dose for this initial pilot study. In the unlikely event that contrast agent 
accumulation reaches a plateau in both of these pathologies or no enhancement is noted on MR scans, 
we will terminate the study after evaluation of n=6 patients (MR data from n=6 patients should allow 
evaluation of significant differences between quantitative pre- and post-contrast signal intensities via a t-
test).  We have submitted an R21 NIH grant proposal which would allow more extensive evaluation of 
patient subgroups (n=5), examined with decreasing ferumoxytol doses.   
 
Stopping rules for an individual test: 
(A) To avoid paravasal injections, the peripheral venous access will be checked with a saline flush prior to 
contrast media injection. In case of any swelling or discoloration at the ferumoxytol injection site (in the 
extremely rare event of a paravasal injection despite prior uncomplicated saline injection), the ferumoxytol 
injection will be stopped immediately, a new peripheral venous access will be placed at the contralateral 
extremity and the remaining ferumoxytol will be slowly administered. In case a local reaction is observed again, 
the ferumoxytol injection will be discontinued completely. 
 
(B) If we observe a decline in blood pressure during the contrast media injection, we will discontinue the 
ferumoxytol injection immediately (in the experience of the PI, a transient hypotension represents a possible 
AE). In case we observe any signs of a potential anaphylactoid reaction (e.g. significant hypotension > 10% 
with associated tachycardia or bradycardia) during the contrast media injection, the injection will be 
discontinued immediately. Patients with mild symptoms such as urticaria, pruritus, rhinorrhea, nausea, 
diaphoresis and/or coughing will be observed for resolution of symptoms or progression. Patients, who show 
severe and/or progressive symptoms, such as arrhythmias, severe hypotension, breathing difficulties, dizziness 
or vomiting will be treated immediately by the M.D. on site and the Pediatric Emergency Care team will be 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 21 of 33 
notified for immediate assistance.  
 
Stopping rules for the study: 
(A) In case of any serious AE, that leads to persistent impairment of a study patient, the study will be 
terminated. 
(B) Anaphylactoid reactions are a possible, but rare side effect of any contrast agent, reported in 1% of 
patients receiving Gd-based contrast agents and 1% of patients receiving ferumoxytol. In case we 
observe an increased incidence of severe anaphylactoid reactions, i.e. more than one patient in our 
limited study population of 20 patients, the study will be terminated. 
(C) According to our statistician, the study population of n=10 patients with sarcomas and n=10 patients 
with osteomyelitis is already very limited and considered a pilot population to demonstrate major 
differences in ferumoxytol enhancement of these two pathologies. In the unlikely event, that contrast 
enhancement reaches a plateau in both pathologies or no enhancement at all is noted in these pathologies 
on MR scans, neither on T2-weighted MR scans nor on T1-weighted MR scans, the study will be 
terminated after evaluation of n=6 patients (MR data from n=6 patients should allow evaluation of 
significant differences between quantitative pre- and post-contrast signal intensities via a t-test). 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 22 of 33 
 
7. ADVERSE EVENTS AND REPORTING PROCEDURES 
 
7.1 
Potential Adverse Events 
 
The most common adverse reactions (≥2%) following administration of Ferumoxytol are diarrhea, nausea, 
dizziness, hypotension, constipation and peripheral edema. Ferumoxytol may cause serious  hypersensitivity 
reactions including anaphylaxis and/or anaphylactoid reactions. In clinical studies, serious hypersensitivity 
reactions were reported in 0.2% of subjects receiving Ferumoxytol.  Hypotension may follow Ferumoxytol 
administration. In clinical studies, hypotension was reported in 1.9 % of subjects. 
 
7.2 
Adverse Event Reporting 
 
In an unanticipated and unlikely event of any adverse event or anaphylactoid reaction to this contrast agent, 
appropriate actions will be taken to treat the reaction and the event will be reported to the IRB. 
 
 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 23 of 33 
8. STUDY CALENDAR :  
 
 
 
Pre study 
 
Initial MRI 
24 hour delayed MRI 
Complete medical history 
 
X 
 
 
Physical Examination 
 
X 
 
 
Vital Signs (Heart rate, 
respiratory 
rate, 
blood 
pressure, temperature) 
 
X 
X 
 
Height 
 
X 
 
 
Weight 
 
X 
X 
 
 ECG 
 
X 
 
 
Pregnancy Test (B-HCG) 
 
X 
 
 
Informed consent 
 
X 
 
 
Investigational agent 
administration 
 
 
X 
 
Adverse event evaluation 
 
 
X 
X 
MRI exam evaluation 
 
 
X 
X 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 24 of 33 
9. MEASUREMENT  
 
9.1 Primary Outcome measures 
 
Primary outcome: To determine contrast enhancement characters on T1 (immediate post contrast) and T2 
(24 hours) weighted MR images, of bone sarcoma and osteomyelitis. 
 
 
9.1.1 Relevant Subset 
 
                 The outcome will be measured on all subjects included in the study. 
 
 
9.1.2 Measurement Definition 
 
To define distinctive MR signal characteristics of bone sarcomas and osteomyelitis. 
Qualitative measurement: An initial precontrast scan of the lesion will be obtained to evaluate the lesion. This 
will serve as an internal control to define the postcontrast effects. Following administration of contrast agent 
ferumoxytol, post contrast MR images will be obtained and enhancement characteristics of the lesion will be 
assessed visually in comparison with the precontrast scan. The following pulse sequences will be applied: Long 
axis T1-spin echo (SE) images and short TI inversion recovery (STIR) images, covering the whole bone from 
joint to joint, axial T2-weighted fat-saturated fast spin echo (FSE) images focusing on the bone lesion, dynamic 
contrast-enhanced T1-weighted 3D spoiled gradient recalled echo (SPGR) images, and axial multi-echo T2*-
weighted gradient echo (GE) images.  
Quantitative measurement: Signal Intensity of the lesion and internal controls will be measured by operator 
defined ROI. Contrast enhancement and signal to noise ratios will be calculated. T2- and T2* relaxation times 
and R2 and R2* relaxation rates of the bone lesions will be calculated based on multiecho T2 weighted 
sequences.  
 
 
9.1.3 Measurement Methods 
 
Primary outcome of these examinations is to define distinctive MR signal characteristics of bone sarcomas and 
osteomyelitis, which will be immediately applicable in a clinical setting.  
The MR signal intensity of the bone lesion, bone marrow, adjacent normal muscle, and background noise will 
be measured by operator defined regions of interest (ROI). The contrast enhancement of the bone lesions will be 
calculated as (SIpre-SIpost)/SIpre x 100%. The bone marrow will serve as a positive internal standard to 
confirm contrast accumulation at the target site and muscle will serve as a negative standard (no enhancement 
expected). Serial signal-to-noise ratios of the lesion on dynamic postcontrast T1-SPGR sequences will be used 
to calculate the blood volume of the lesion and microvascular permeability of ferumoxytol via kinetic analyses 
as described previously. 
 
 
9.1.4 Measurement Time Points: 
           
 Data analysis of the initial MR scan and 24hr Delayed MR scans will be performed 
 
 
9.1.5 Response Review 
 
                  All MR images will be reviewed by two blinded readers.   
The results of both readers will be included in data and statistical analysis. Inter-reader agreement will also be 
evaluated by K statistics. 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 25 of 33 
10. 
REGULATORY CONSIDERATIONS  
 
10.1 Monitoring plan 
 
The Stanford Cancer Center Data and Safety Monitoring Committee (DSMC) will be the monitoring entity for 
this study. The DSMC will audit study-related activities approximately once per year to determine whether the 
study has been conducted in accordance with the protocol, local standard operating procedures, FDA 
regulations, and Good Clinical Practice (GCP).  In addition, the DSMC will regularly review serious adverse 
events and protocol deviations associated with the research to ensure the protection of human subjects. Results 
of the DSMC audit will be communicated to the IRB and the appropriate regulatory authorities at the time of 
continuing review, or in an expedited fashion, as needed.  
 
10.2  Protocol Review and Amendments 
 
The protocol, the proposed informed consent and all forms of participant information related to the study (e.g. 
advertisements used to recruit participants) will be reviewed and approved by the Stanford IRB and Stanford 
Cancer Center Scientific Review Committee (SRC).  Any changes made to the protocol will be submitted as a 
modification and will be approved by the IRB prior to implementation.  The Protocol Director will disseminate 
the protocol amendment information to all participating investigators.  
 
 
10.3 Data management  
 
Patient data/demographics will be kept in the RedCap clinical research database tool provided by Stanford 
University's Clinical Informatics department (clinicalinformatics.stanford.edu). Images are kept in the clinically 
supported and secured PACs system, until a researcher exports de-identified images for publication. Identified 
information will only be kept in either a secure clinical system or the secure RedCap database; all exported data 
will be de-identified. 
 
 
10.4 Study Documentation 
 
The Protocol Director, or her designee, will prepare and maintain adequate and accurate participant case 
histories with observations and other data pertinent to the study.  Original source documents should be 
transcribed to Case Report Forms (CRFs) and used to analyze the study data.  Source documents include 
hospital records, clinical charts, laboratory and pharmacy records, and recorded electronic data 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 26 of 33 
11. STATISTICAL CONSIDERATIONS 
 
11.1 
Statistical Design 
 
11.1.1Randomization 
Non Randomized 
 
11.2 
Primary Analysis 
 
                          11.2.1          Analysis Population 
All MR images of the study population will be included in the analysis. In case of missing data or non-
adherence to protocol, the subject will be excluded from analysis. 
 
              11.2.2           Analysis Plan 
Descriptive statistics will be used to characterize contrast enhancement and relaxation times in both T1 and T2* 
settings, in each population; the key estimates will be the standard deviation and the coefficient of variation. 
 The area under the ROC curve will be calculated as a measure of separation and the significance of the 
separation will be assessed using the Wilcoxon rank sum test. 
                                                       
        11.3            Sample Size 
 
             11.3.1           Accrual estimates 
 
We plan to enroll 20 patients in this pilot study, 10 patients with bone sarcomas and 10 patients with an 
osteomyelitis. Osteomyelitis is a relatively common disease, while bone sarcoma is relatively rare and we 
expect to enroll 1-2 subjects per month of both these pathologies. 
 
           11.3.2           Sample size justification 
 
This is a pilot study to establish proof of concept  and obtain data for future investigations.  If applicable, the 
precision of the data could be summarized with a pooled standard deviation, which is expected to have 18 
degrees of freedom.  A future sample size calculated on that basis would have a 30% probability of  
underestimating a sample size by as much as 20%, and a 4% probability of underestimating a sample size by as 
much as 50%.  For the record the sample sizes in the present study provide 80% power to detect a  
difference of 1.33 standard deviations, but we have no information on the magnitude of a clinically relevant 
difference. 
 
 
       11.4           Criteria for future studies 
 
With this pilot study we want to determine the distinctive contrast enhanced MR signal characteristics of Bone 
Sarcoma and Osteomyelitis. Subsequent future studies will evaluate the actual macrophage quantity within the 
study lesions. 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 27 of 33 
REFERENCES 
 
Provide the citations for all publications referenced in the text. 
(1) Ewing J. Classics in oncology. Diffuse endothelioma of bone. James Ewing. Proceedings of the New York 
Pathological Society, 1921. CA Cancer J Clin 1972;22(2):95-8 
(2) Petrikowski CG, Pharoah MJ, Lee L, Grace MG. Radiographic differentiation of osteogenic sarcoma, 
osteomyelitis and fibrous dysplasia of the jaws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995 
Dec;80(6):744-50. 
(3) Lyall H, Constant C, Wraight E. Case report: Ewing's sarcoma in distal tibial metaphysis mimicking 
osteomyelitis. Clinical Radiology 48(2): 140-142 
(4) Mellado Santos, JM. Diagnostic imaging of pediatric hematogenous osteomyelitis: lessons learned from a 
multi-modality approach. Eur Radiol 2006, 16(9): 2109-2119 
(5) Pai AB, Nielsen JC, Kausz A, Miller P, Owen JS. Plasma pharmacokinetics of two consecutive doses of 
ferumoxytol in healthy subjects. Clin Pharmacol Ther. 2010;88(2):237-42 
(6) Lu M, Cohen MH, Rieves D, Pazdur R. FDA report: Ferumoxytol for intravenous iron therapy in adult 
patients with chronic kidney disease. Am J Hematol. 2010;85(5):315-9 
(7) Provenzano R, Schiller B, Rao M, Coyne D, Brenner L, Pereira BJ. Ferumoxytol as an intravenous iron 
replacement therapy in hemodialysis patients. Clin J Am Soc Nephrol. 2009; 4(2):386-93 
(8) Schwenk MH. Ferumoxytol: a new intravenous iron preparation for the treatment of iron deficiency anemia 
in patients with chronic kidney disease. Pharmacotherapy. 2010;30(1):70-9 
(9) Simon GH, von Vopelius-Feldt J, Fu Y, Schlegel J, Piontek G, Wendland MF, Mei-Hsiu C, Daldrup-Link 
HE: Ultrasmall superparamagnetic iron oxide-enhanced magnetic resonance imaging of antigen-induced 
arthritis: a comparative study between SHU555C, Ferumoxtran-10 and Ferumoxytol. Investigative Radiology 
2006; 41(1):45-51 
(10) Gahramanov S, Raslan AM, Muldoon LL, Hamilton BE, Rooney WD, Varallyay CG, Njus JM, Haluska 
M, Neuwelt EA. Potential for Differentiation of Pseudoprogression from True Tumor Progression with 
Dynamic Susceptibility-weighted Contrast-enhanced Magnetic Resonance Imaging using Ferumoxytol vs. 
Gadoteridol: A Pilot Study. Int J Radiat Oncol Biol Phys. 2010 Apr 13. [Epub ahead of print] 
(11) Reimer P, Rummeny EJ, Daldrup HE, Tombach B, Berns T, Balzer T, Peters PE: Clinical Results with 
Resovist: A Phase 2 Clinical Trial. Radiology 1995; 195: 489-496 
(12) Daldrup HE, Link TM, Blasius S, Könemann S, Jürgens H, Rummeny EJ: Monitoring Radiation-Induced 
Changes in Bone Marrow Histopathology with Ultra-Small Superparamagnetic Iron Oxide (USPIO) Enhanced 
MRI. J Magn Reson Imaging 1999, 9: 643-652  
(13) Daldrup-Link HE, Rummeny EJ, Ihßen B, Kienast K, Link TM: Iron oxide enhanced MR imaging of bone 
marrow in patients with non-Hodgkin`s lymphoma: differentiation of tumor infiltration and hypercellular bone 
marrow. Europ Radiol  2001; 11: 1276-1284 
(14) Daldrup-Link HE, Rydland J, Helbich T, Turetschek K, Haraldseth O, Link TM, Brasch RC, Shames D, 
Rummeny EJ: Quantitative MRI-Estimates of breast tumor microvascular permeabilities to the macromolecular 
contrast agent Feruglose (Clariscan) correlate with histologic tumor grade: Initial Phase II Multicenter Trial. 
Radiology 2003; 229(3): 885-92 
(15) Metz S, Bonaterra G, Rudelius M, Settles M, Rummeny EJ, Daldrup-Link HE: Capacity of Human 
Monocytes to phagocytose approved iron oxide MR contrast agents. Eur Radiol 2004; 14(10):1851-8 
(16) Daldrup-Link HE, Rudelius M, Piontek G, Metz S, Bräuer R, Debus G, Corot C, Schlegel J, Link TM, 
Peschel C, Rummeny EJ, Oostendorp RAJ: Migration of iron oxide labeled human hematopoietic progenitor 
cells in a xenotransplant model: in vivo monitoring using clinical magnetic resonance imaging equipment. 
Radiology 2005; 234(1): 197-205 
(17) Daldrup-Link HE, Meier R, Rudelius M, Piontek G, Piert M, Metz S, Settles S, Uherek C, Schlegel J, 
Rummeny EJ: In-vivo Tracking of genetically engineered anti-HER2/neu directed Natural Killer to HER2/neu 
positive Mammary Tumors with Magnetic Resonance Imaging. Eur Radiol 2005; 15(1): 4-13 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 28 of 33 
(18) Simon GH, von Vopelius-Feldt J, Wendland M, Schlegel J, Mei-Hsiu C, Daldrup-Link HE: Ultrasmall 
superparamagnetic iron oxide enhanced MR imaging of normal bone marrow in rodents. Academic Radiology 
2005; 12(9):1190-7 
(19) Simon GH, von Vopelius-Feldt J, Wendland M, Fu Y, Piontek G, Schlegel J, Chen, MH, Daldrup-Link 
HE: MRI of arthritis: Comparison of ultrasmall superparamagnetic iron oxide vs. Gd-DTPA. Journal of 
Magnetic Resonance Imaging 2006; 23(5):720-7 
(20)  Metz S, Lohr S, Settles S, Beer A, Woertler M, Rummeny EJ, Daldrup-Link HE: Ferumoxtran-10 
enhanced MR imaging of the bone marrow before and after conditioning therapy in patients with Non Hodgkins 
Lymphoma. Eur Radiol. 2006; 16(3):598-607, 2006 
(21) Simon GH, Bauer J, Saborowski O, Fu Y, Corot C, Wendland MF, Daldrup-Link HE: T1 and T2 relaxivity 
of intracellular and extracellular USPIO at 1.5T and 3T clinical MR scanning. Eur Radiol. 2006; 16(3):738-45 
(22) Henning TD, Wendland MF, Golovko D, Sutton EJ, Sennino B, Malek F, Bauer JS, McDonald DM, 
Daldrup-Link HE: Relaxation effects of ferucarbotran-labeled mesenchymal stem cells at 1.5T and 3T: 
discrimination of viable from lysed cells. Magn Reson Med 2009; 62(2):325-332 
(23) Golovko D, Henning T, Bauer JS, Settles M, Frenzel T, Mayerhofer A, Rummeny E, Daldrup-Link HE: 
Accelerated stem cell labeling with ferucarbotran and protamine. Eur Radiol. 2010; 20(3): 640-8 
(24) Meier R, Henning TD, Boddington S, Tavri S, Arora S, Corot C, Daldrup-Link HE: Breast cancers: MR 
imaging of folate receptor expression with the folate-specific nanoparticle P1133. Radiology 255(2):527-35 
(25) Henry TD, Mary E. McCarville ME, Hoffer, FA. Diagnostic Imaging of Pediatric Bone and Soft Tissue 
Sarcomas. Pediatric Oncology, 2006, 35-69 
(26) Gyoerke T. Impact of FDG PET for staging of Ewing sarcomas and primitive neuroectodermal tumours. 
Nuclear Medicine Communications 2006; 27(1): 17-24 
(27) Kan JH. Major pitfalls in musculoskeletal imaging–MRI. Ped Radiol 2008, 38, Supplement 2, 251-255 
(28) Mathur K, Nazir AA, Sumathi VP, Kumar T. Ewing’s sarcoma masquerading as chronic osteomyelitis: a 
case report. Eur J of Orthop Surgery & Traumatology 2005; 16(2):175-177 
(29) Kleis M, Daldrup-Link H, Matthay K, Goldsby R, Lu Y, Schuster T, et al. Diagnostic value of PET/CT for 
the staging and restaging of pediatric tumors. Eur J Nucl Med Mol Imaging 2009;36(1):23-36 
Article I. 
(30) Metcalfe J, Grimer R. Ewing's sarcoma of the foot masquerading as osteomyelitis. Foot and 
Ankle Surgery 2004, 10(1) 29-33 
(31) Tow BPB, Tan MH. Delayed diagnosis of Ewing’s sarcoma of the right humerus initially treated as chronic 
osteomyelitis: A case report. Journal of Orthopaedic Surgery 2005:13(1):88-92 
(32) Durbin M, Randall RL, James M, Sudilovsky D, Zoger S. Ewing’s sarcoma masquerading as osteomyelitis. 
Clin Orthop 1998; (357):176–85 
(33) Akeda K, Kasai Y, Kawakita E, Seto M, Kono T, Uchida A. Primary Ewing Sarcoma of the Spine 
Mimicking a Psoas Abscess Secondary to Spinal Infection. Spine 2009, 34(9): E337-E341 
Section 1.01 (34) Lichtenstein M, Andrews J, Scales R. Localization of osteomyelitis with 99m technetium 
sulfur colloid. Australian and New Zealand Journal of Surgery 1983; 53(4): 339–342 
(35) Bierry G, Jehl F, Neuville A, Lefevre S, Robert P, Kremer S, Dietemann JL. MRI of macrophages in 
infectious knee synovitis. AJR Am J Roentgenol. 2010;194(6):W521-6 
(36) Prince MR, Zhang HL, Chabra SG et al. A pilot investigation of new superparamagnetic iron oxide 
(ferumoxytol) as a contrast agent for cardiovascular MRI. J X-Ray Sci Tech 2003; 11:231-240. 
(37) Ersoy H, Jacobs P, et al. (2004). Blood pool MR angiography of aortic stent-graft endoleak. AJR Am J 
Roentgenol 182(5): 1181-6. 
(38) Li W, Tutton S, et al. (2005). First pass contrast enhanced magnetic resonance angiography in humans 
using ferumoxytol, a novel ultrasmall superparamagnetic iron oside (USPIO)-based blood pool agent. J Magn 
Reson Imaging 21(1): 46-52 
(39) Li W, Salanitri J, et al (2007). Lower extremity deep venous thrombosis: evaluation with ferumoxytol-
enhanced MR imaging and dual-contrast mechanism—preliminary experience. Radiology 242(3): 873-81. 
(40) Neuwelt EA Varallyay CG, et al (2007). The potential of ferumoxytol nanoparticle magnetic resonance 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 29 of 33 
imaging, perfusion and angiography in central nervous system malignancy: a pilot study. Neurosurgery 
60(4):601-11; discussion 611-2. 
41) Palestro CJ , Love C , Tronco GG , Tomas MB , Rini JN . Combined labeled leukocyte and technetium 99m 
sulfur colloid bone marrow imaging for diagnosing musculoskeletal infection. Radiographics. 2006 May-
Jun;26(3):859-70. 
42) Strobel K, Stumpe KD. PET/CT in musculoskeletal infection. Semin Musculoskelet Radiol . 2007 
Dec;11(4):353-64. Review . 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 30 of 33 
APPENDIX A: Participant Eligibility Checklist  
 
A Participant Eligibility Checklist must be completed in its entirety for each subject prior to registration. The 
completed, signed, and dated checklist must be retained in the patient’s study file and the study’s Regulatory 
Binder.  
 
 
Protocol Title: 
 Differentiation of bone sarcomas and osteomyelitis with 
Ferumoxytol-Enhanced MRI 
 
Protocol Number: 
20253 
Principal Investigator: 
Dr.Heike Daldrup-Link 
 
II. Subject Information: 
 
Subject Name/ID: 
 
Gender:    
 Male     
 Female 
III. Inclusion/Exclusion Criteria 
 
Inclusion Criteria 
(From IRB approved protocol) 
Yes 
No 
Supporting 
Documentation* 
1. 10-21 years in age 
 
 
      
2. Suspected or confirmed diagnosis of 
osteosarcoma or osteomyelitis 
 
 
      
Exclusion Criteria 
(From IRB approved protocol) 
 
1. Contraindication to MRI (metal 
implants) 
 
 
      
2. Need for sedation or anesthesia 
(claustrophobia) 
 
 
      
3. hemosiderosis/ hemochromatosis 
 
 
      
 
*All subject files must include supporting documentation to confirm subject eligibility.  The method of 
confirmation can include, but is not limited to, laboratory test results, radiology test results, subject self-report, 
and medical record review.   
IV.  Statement of Eligibility 
 
This subject is [ 
 eligible / 
 ineligible ] for participation in the study. 
 
 
Signature: 
Date: 
Printed Name: 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 31 of 33 
APPENDIX B: Case Report Forms 
I. Patient History 
 
Patient Name: 
Medical Record #: 
Birth Date: 
Patient body weight: 
Gender: 
Patient height: 
Medications: 
 
 
 
Allergies:  
 
Inclusion Criteria: 
  
  
Age: 10-21 years 
yes  
no  
suspected or confirmed diagnosis of a bone 
sarcoma or osteomyelitis 
yes 
no 
Exclusion Criteria: 
yes  
no  
Hemosiderosis/Hemochromatosis 
yes  
no  
History of any allergies to contrast agents  
or any severe allergies to other substances 
yes  
no  
Claustrophobia 
yes  
no  
MR-incompatible metal implants 
yes  
no  
Any significant previous illnesses or injuries: 
(date / completed or ongoing) 
Any previous surgeries: 
(date / completed or ongoing) 
CNS: 
 
CNS: 
 
Head/Neck: 
 
Neck: 
 
Chest: 
 
Chest: 
 
Abdomen/Pelvis: 
 
Abdomen/Pelvis: 
 
MSK: 
 
MSK: 
 
Psychological / Emotional: 
 
Psychological / Emotional: 
 
Other: 
 
Other: 
 
Details: 
 
 
 
 
 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 32 of 33 
 
II. Physical Examination 
 
Patient Name: 
Medical Record #: 
Patient body weight: 
Patient height: 
Blood Pressure: 
Pulse rate: 
ECG date (within 30 d prior to Ferumoxytol MR): 
ECG report (summary): 
 
 
Clinical Evaluation: 
normal 
abnormal 
Describe abnormal findings 
CNS 
 
 
 
 
Head/Nose/Mouth 
 
 
 
 
Ears 
 
 
 
 
Eyes 
 
 
 
 
Neck 
 
 
 
 
Lungs / Auscultation 
 
 
 
 
Heart / Auscultation 
 
 
 
 
Abdomen 
 
 
 
 
Pelvis 
 
 
 
 
Spine 
 
 
 
 
Upper Extremities 
 
 
 
 
Lower Extremities 
 
 
 
 
Skin 
 
 
 
 
Pregnancy test (within 24 h prior to contrast media injection): 
Other: 
 
 
 
 
 
 
 
 
 
 
 


TEMPLATE – Stanford Cancer Center 
 
 
   October 11, 2010 
 
Page 33 of 33 
 
III. Contrast Media Administration 
 
Patient Name: 
Patient weight: 
Birth Date: 
Ferumoxytol dose (5 mg/kg):  
Medical Record #: 
Ferumoxytol volume:  
= weight (kg) x dose (5 mg Fe/kg) / 30 mg Fe/ml 
Ferumoxytol injection, date (dd/mm/yyyy) and start time (hh/min): 
Ferumoxytol injection end time (hh/min): 
Planned injection rate: 10 ml / min 
Actual injection rate:  
Contrast agent completely injected:  yes  / no 
Actual injection volume:  
Evidence of paravasal injection: yes / no 
Local Reaction at injection site: yes / no 
Vital signs: 
pre 
0 min 
15 min 
30 min 
45 min 
60 min 
90 min 
Heart Rate 
 
 
 
 
 
 
 
Respiratory rate 
 
 
 
 
 
 
 
Blood pressure 
 
 
 
 
 
 
 
Temperature 
 
 
 
 
 
 
 
Any objective or subjective 
adverse reaction (time): 
 
 
 
 
 
 
 
Any objective or subjective 
adverse reaction (describe): 
 
 
 
 
 
 
 
 
 
 
 
IV. MR Imaging 
 
Acquired pulse sequences 
Date of MR 1 (dd/mm/yyyy): 
Date of MR 2 (dd/mm/yyyy): 
 
precontrast 
1-60 min p.i. 
24 h p.i. 
T1-SE 
 
 
 
STIR 
 
 
 
T2-TSE 
 
 
 
T2*-GE 
 
 
 
Other (specify) 
 
 
 
Other (specify) 
 
 
 
(add pulse sequence parameters: TR/TE/alpha/slice thickness/orientation)