Conditions: Glioma
Keywords: glioma high grade glioma, low grade glioma
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 199
Healthy volunteers: no

Brief summary:
The prodrug, 5-Aminolevulinic acid (ALA), has been shown to lead to intracellular accumulation of fluorescent porphyrins in high grade malignant gliomas in the brain. On imaging, this accumulation of fluorescent porphyrins helps delineate tumor borders, resulting in the surgeon being better able to visualize and thus able to make a complete, or near-complete resection of the tumor.

Detailed description:
The drug, 5-aminolevulinic acid (ALA), which leads to intracellular accumulation of fluorescent porphyrins in gliomas will be used under investigation for identification and resection of high and low grade gliomas. Surgery will be done using a modified neurosurgical microscope, with a fluorescent kit that enables switching from the conventional white light to a violet-blue excitation light for visualization during tumor resection. If deemed safe by the neurosurgeon, any area of the resection bed determined to be fluorescence-positive for tumor will be removed with appropriate designation of tissue for histopathological evaluation. After this resection, additional fluorescence images will be obtained and the process repeated until the image is negative for tumor. At all times, the decision to resect will be limited by clinical judgment of safety.

The desire is that a more complete resection will occur due to the surgeon's ability to better visualize and distinguish between tumor and normal tissue, and thus be able to remove as much, or most of, the tumorous tissue, resulting in a better outcome for the patient, or for future patients.

Arms:
arm 1: Up to 300 patients with diagnosed glioma (WHO G1-IV) eligible for surgery will be entered into the trial and will be given 5-Aminolevulinic Acid (ALA) orally at a dose of 20mg/kg body weight preoperatively

Interventions: intervention 1: 5-Aminolevuline Acid (ALA)
Intervention descriptions: intervention 1: Given orally at a dose of 20 mg/kg body weight 3hrs before anesthesia prior to surgery

Protocol document:
Prot_SAP_000.pdf: 
Confidential 
Amendment No. 4 
 
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CLINICAL PROTOCOL 
 
TITLE: 
A Phase 2 Study of Aminolevulinic Acid (ALA) to Enhance Visualization and 
Resection of Tumors of the Brain 
 
Principal Investigator: 
Mitchel S. Berger, MD 
 
Study Center: 
University of California Medical Center, San Francisco 
 
505 Parnassus Ave., Rm. M779 
 
San Francisco, CA 94143-0112 
 
Responsible Research  
Nurse: 
Jane Rabbitt, RN, BSN 
 
Marlene D. Burt, RN, MS, ACNP 
 
 
Responsible Data  
Manager: 
Ashley DeSilva, BS  
 
 
 
 
ORIGINAL: 
02 February 2010 
 
 
DATE AMENDED: 
01 October 2010 
 
Amendment Number: 1.0 
 
 
 
 
DATE AMENDED: 
05 July 2011  
 
Amendment Number: 2.0 
 
 
DATE AMENDED: 
02 February 2012 
 
Amendment Number: 3.0 
 
 
DATE AMENDED: 
14 March 2013 
 
Amendment Number: 4.0 


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TABLE OF CONTENTS 
Page 
1. OVERVIEW ....................................................................................................................... 4 
2. OBJECTIVES ..................................................................................................................... 5 
2.1 
Primary Objective ................................................................................................... 5 
2.2 
Secondary Objective ............................................................................................... 5 
3. BACKGROUND ................................................................................................................ 5 
3.1 
5-Aminolevulinic Acid (ALA) ............................................................................... 6 
3.2 
Invasive Brain Tumor ............................................................................................. 7 
3.3 
Rationale for ALA .................................................................................................. 8 
4. PATIENT SELECTION ..................................................................................................... 8 
4.1 
Eligibility Criteria ................................................................................................... 8 
4.2 
Exclusion Criteria  .................................................................................................. 9 
4.3 
Inclusion of Women and Minorities ....................................................................... 9 
4.4 
Study Calendar ........................................................................................................ 10 
5. TREATMENT PLAN ......................................................................................................... 11 
5.1 
Pre-surgical Procedure ............................................................................................ 11 
5.2 
Surgical Procedure .................................................................................................. 11 
5.3 
Extent of Resection Follow-up ............................................................................... 12 
5.4 
Supportive Care ...................................................................................................... 12 
6. REGULATORY REPORTING REQUIREMENTS .......................................................... 13 
6.1 
UCSF Data Safety Monitoring Plan for Phase II or III Institutional Study ............ 13 
6.2 
Monitoring and Reporting Guidelines .................................................................... 13 
6.3 
Review and Oversight Requirements...................................................................... 13 
6.3.1 
Adverse Event Monitoring ................................................................................ 13 
6.3.2 
Review of Adverse Event Rates ....................................................................... 14 
6.3.3 
Study Progress – Quarterly Review .................................................................. 14 
6.4 
Adverse Event Reporting ........................................................................................ 15 
6.4.1 
Probable ALA adverse events to be expected................................................... 16 
6.4.2 
Other possible adverse events ........................................................................... 16 
6.5 
Environmental Assessment ..................................................................................... 17 
7. STATISTICAL CONSIDERATIONS................................................................................ 17 
7.1 
Study Endpoints ...................................................................................................... 17 
7.2 
Sample Size Determination..................................................................................... 18 
7.3 
Statistical Analysis .................................................................................................. 19 
8. REFERENCES ................................................................................................................... 20 


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APPENDICES 
Page 
Appendix A 
Patient Informed Consent ................................................................................. 24 
Appendix B 
Performance Status Criteria .............................................................................. 29 
Appendix C 
Operating Room Ultraviolet-illuminated Microscope ...................................... 30 
 
 


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1. 
OVERVIEW 
Title 
A Phase 2 Study of Aminolevulinic Acid (ALA) to Enhance Visualization and 
Resection of Tumors of the Brain 
Primary Objective 
To determine if the use of 5-aminolevulinic acid (ALA) helps distinguish tumor 
cells from normal cells leading to an increase in the amount of tumor removal 
during neurosurgical resection of glioma. 
Secondary Objective 
Determine the safety of a single dose of 5-aminolevulinic acid (ALA) 
administered preoperatively at a dose of 20 mg/kg body weight. 
Study product and route of administration 
5-Aminolevulinic Acid (ALA) will be given orally at a dose of 20 mg/kg body weight. 
Participants 
300 individuals (age 18 to 72 years) with diagnosed glioma (WHO GI-IV) eligible 
for surgery will be entered into the trial. 
50 participants will be enrolled into each of the following subgroups: 
 
1) Newly diagnosed GBM 
2) Newly diagnosed grade II glioma (astrocytic, oligodendroglial, and mixed) 
3) Recurrent GBM 
4) Recurrent grade III glioma (astrocytic, oligodendroglial, and mixed) 
5) Newly diagnosed low grade glioma (astrocytic, oligodendroglial, 
ganglioglial, and mixed) 
6) Recurrent low grade glioma (astrocytic, oligodendroglial, ganglioglial, and 
mixed) 
Design 
Single center open label phase 2 trial 
Estimated total study duration 
Twenty four months 
Investigational New Drug (IND) sponsor 
Mitchel S. Berger, M.D., Director, Brain Tumor Research Center 
University of California Medical Center, San Francisco 


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Study drug provider 
DUSA Pharmaceuticals/Sun Pharma, Tarrytown, NY 
Statistical and data management 
UCSF Department of Neurological Surgery  
Safety Monitoring 
Adverse events will be collected from the time of drug administration.  NCI Common 
Terminology Criteria for adverse events (CTCAE) version 3.0 will be utilized for adverse 
event reporting. 
 
2. 
OBJECTIVES 
 
2.1 
Primary Objective: 
To determine if the use of 5-aminolevulinic acid (ALA) helps distinguish tumor cells 
from normal cells leading to an increase in the amount of tumor removal during 
neurosurgical resection of glioma.  
 
2.2 
Secondary Objective: 
Determine the safety of a single dose of 5-aminolevulinic acid (ALA) administered 
preoperatively at a dose of 20 mg/kg body weight. 
 
3. 
BACKGROUND 
Gliomas are locally invasive tumors in the brain that are very infiltrative and are 
associated with a poor prognosis. Currently there is no adequate way to properly identify these 
tumors during the course of surgical resection other than by gross visualization.  A number of 
studies have shown that the extent of resection definitely affects outcome in terms of survival 
and progression-free survival (1-6).  Nevertheless, surgical studies (2-7) have indicated that 
complete resection of contrast-enhancing tumor is achieved in only about 20-30% of patients and 
can be considered likely due to difficulty in determining the overall marginal area of the tumor 
(2).  Therefore, it is considered important to achieve the greatest extent of resection possible, 
reducing the mass of the tumor, prior to administered therapy.  Several technical surgery 
supports have been explored that include magnetic resonance imaging (MRI) (8), 
neuronavigation (9), and ultrasound (10) but little data from prospective randomized trials exists.  
The standard mode being used, with few exceptions, still relies on preoperative imaging studies 
to guide the course of resection, as well as the use of clinical acumen. 
Over the last several years, 5-aminolevulinic acid (ALA) has been used in Europe to 
illuminate the tumor and its infiltrative margin and to compare it to white light-based surgery 
(11) and has been granted marketing approval by the European Medicines Evaluation Agency for 
use in the European community in adult patients for visualization of malignant tissue during 


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surgery for malignant glioma (World Health Organization Grades III and IV).  ALA is a natural 
biochemical precursor of hemoglobin that elicits synthesis and accumulation of fluorescent 
porphyrins in various epithelia and cancerous tissue (12).  ALA has been shown in experimental 
and clinical studies to be taken up by malignant glioma cells, where it is converted into 
fluorescing porphyrins (13).  Strummer, et al. 2006, reports that fluorescence-guided resection by 
use of 5-aminolevulinic acid (ALA) is easy to do, and does not interrupt the operation (11).  
Such resection relies on specific synthesis and accumulation by 5-aminolevulinic acid of 
fluorescent porphyrins in malignant glioma tissue (14, 15).  The technique differs from earlier 
attempts to use a fluorescent agent, such as fluorescein (16), in which the fluorescing agent is in 
the plasma and reaches the tumor through the disrupted blood-brain barrier, limiting specificity.  
The European data has been very supportive in terms of facilitating the extent of resection and 
improving 6-month progression-free survival (11). 
 
3.1 
5-Aminolevuline Acid (ALA) 
C5H9NO3 MW 167.6  
 
ALA is a naturally occurring substance that is found in all organisms, including humans, 
and is necessary for part of the basic metabolic life processes.  Approximately 350 mg of ALA is 
synthesized in humans each day for endogenous heme production.  Administration of exogenous 
5-ALA results in the production of high intracellular (mitochondrial) concentrations of 
Protoporphyrin IX (Pp IX).  ALA (and other porphyrins) and Pp IX are excreted in the urine and 
the stool (via bile), respectively. DUSA Pharmaceuticals/Sun Pharma is located in Tarrytown, 
NY and will be the provider of the product. DUSA Pharmaceuticals/Sun Pharma has investigated 
the use of ALA and studied its pharmacology, pharmacokinetics, and toxicity. 
Pharmacology 
The metabolism of aminolevulinic acid is the first step in the biochemical pathway 
resulting in heme synthesis.  ALA is not a photosensitizer, but rather a metabolic precursor of Pp 
IX, which is the photosensitizer.  Synthesis of ALA is normally controlled by feedback inhibition 
of the enzyme, ALA synthetase, presumably by intracellular heme levels.  ALA, when provided 
to the cell, bypasses this control point and results in the accumulation of Pp IX, which is 
converted into heme by ferrochelatase through the addition of iron to the Pp IX nucleus. 
Pharmacokinetics 
ALA and Pp IX were measured in plasma in a human pharmacokinetic study using a 128 
mg dose of sterile intravenous ALA HCl and oral ALA HCl (equivalent to 100 mg ALA).  The 
mean half-life of ALA was 0.70 ± 0.18 hour after the oral dose and 0.83 ± 0.05 hour after the 
intravenous dose.  The oral bioavailability of ALA was 50-60% with a mean Cmax of 4.65 ± 
0.94 µg mL.  Pp IX concentrations were low and were detectable only in 42% of the plasma 
samples.  Pp IX concentrations in plasma were quite low relative to ALA plasma concentrations, 
and were below the level of detection (10 ng/mL) after 10 to 12 hours. 
Toxicity 


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In vivo pharmacological and toxicological effects that may be associated with elevated 
systemic levels of ALA, Pp IX, and other intermediates of porphyrin biosynthesis in humans are 
well known, and characterize a group of metabolic diseases known as the porphyrias.  An 
association between high systemic concentrations of ALA and neurological abnormalities is 
observed in Acute Intermittent Porphyria (AIP).  However, attempts at clarifying the association 
between elevated ALA and the neurological symptoms of AIP have led to inconsistent results 
and contradictory conclusions.  Most studies have shown that ALA and Porphobilinogen (PBG 
equals condensation of 2 molecules of ALA) are not neurotoxic in vivo when administered in 
large amounts to animals and humans.  Concentration of these precursors in the brain or 
cerebrospinal fluid (CSF) of porphyric patients is substantially below that required for 
demonstrable toxicity in vitro.  Litman and Correia, 1985, hypothesized that depletion of hepatic 
heme, as seen in AIP, leads to elevated tryptophan content and 5-hydroxytryptamine turnover in 
the brain, and is responsible for the neurological symptoms of AIP (17).  On this basis then, 
administration of exogenous ALA would not lead to a depletion of hepatic heme and, therefore, 
would not be expected to elicit the neurological symptoms of AIP.  Photosensitivity, associated 
with high systemic levels of Pp IX, is a typically finding in Erythropoietic Protoporphyria (EPP) 
which is associated with decreased activity of ferrochelatase, the enzyme that converts Pp IX to 
heme.  EPP is entirely cutaneous, with none of the hemolytic or neurological problems of other 
porphyrias. 
Mild transient nausea and occasional vomiting have been observed following oral 
administration of high doses of ALA.  Webber et al. 1997, observed that almost one-quarter of 
all patients who retained ALA had at least one abnormality in liver function tests (18). Nausea 
and vomiting were seen in 20% of the patients but no other symptoms of porphyria. 
The most common complaint, due to Pp IX photosensitization, is very unpleasant 
pricking, itching or burning sensation under the skin after exposure to the sun.  A systemic load 
above 10 mg/kg is required to develop skin photosensitization (DUSA Pharmaceuticals/Sun 
Pharma), which lasts from approximately 24 to 48 hours following ALA administration. 
 
3.2 
Invasive Brain Tumor 
The tumor may take on a variety of appearances, depending on the amount of 
hemorrhage, necrosis, or its age.  An MRI will usually show a nonhomogeneous mass with a 
hypodense center and a variable ring of enhancement surrounded by edema.  Mass effect from 
the tumor and edema may compress the ventricles and cause hydrocephalus.  Cancer cells with 
stem cell-like properties have been found in glioblastoma (this may be a cause of their resistance 
to conventional treatments, and high re-occurrence rate (19). 
The current treatment of patients with brain tumors is traditionally divided into surgical, 
radiotherapeutic, chemotherapeutic, and experimental treatments.  Surgery is usually performed 
to either fully resect or debulk the gross portion of the tumor (contrast-enhancing portion).  
Although surgery alone rarely cures a malignant brain tumor, reduced tumor burden allows the 
body’s own immune system or adjuvant therapies a greater chance of success.  Biopsies are 
usually reserved for tumors in areas of the brain that are considered eloquent (harboring critical 
cerebral functions; i.e. language, motor, vision, functions, etc.) or when the patient’s medical 
condition does not predict a safe surgical outcome.  Radiotherapy plays a central role in the 


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management of brain tumors in individuals older than 4 years of age.  Radiotherapy is generally 
regional, with a boost to the tumor bed, for a total of 6,000 cGy over 30 treatments in 6 weeks.  
Chemotherapy continues to be offered to brain tumor patients as adjuvant treatment.  It is usually 
delivered intravenously but oral agents such as Temodar have shown some efficacy.  
Chemotherapy impregnated wafers (BCNU) are sometimes implanted at the time of surgery.  
Experimental protocols, including immunotherapy and gene therapy, round out the efforts 
attempting to better treat these deadly neoplasms. 
The median survival of a patient undergoing biopsy of GBM without surgical resection or 
further treatment is -8 weeks.  For those patients who undergo surgery alone, the median survival 
increases to 17 weeks.  The addition of radiation therapy post-surgical resection raises median 
survival to approximately 37 weeks; chemotherapy adds an additional few weeks to this median 
survival.  Overall, the 5-year relative survival rate for a primary malignant glioma is age 
dependent.  Survival rates are 63.1% for age 0-19, 50.4% for age 20-44, 14.2% for age 45-64, 
and 4.9% for age >65.  Recurrence of the tumor at the site of surgical resection is the rule.  The 
recurrence is within 2cm. of the margin of the resection cavity in 80% of cases.  For patients with 
recurrent tumors undergoing repeat surgical resection, the re-operation may add as much as 14 to 
30 weeks of additional survival.  Nevertheless, this response is met with fatal growth in virtually 
all patients.  The 5-year survival rate is less than 5%. 
Lower grade tumors offer better prognosis. Median survival is 5.9 years when treated 
with biopsy alone. However, early resection of low grade tumors improves 5-year survival to 
74% compared to 60% for biopsy and watchful waiting (19). As in malignant glioma, survival 
rates are age dependent. The ten-year survival rates are 86% for age 0-20, 53% for age 20 to 64, 
and 20% for age >64. Maximal tumor resection may improve both symptoms and survival rates 
(6, 20). 
 
3.3 
Rationale for ALA 
5-aminolevulinic acid (ALA) is a naturally occurring amino acid and a precursor in heme 
biosynthesis.  ALA is produced at the cytosolic surface of the mitochondrial membrane and then 
transported to the cellular cytosol for heme biosynthesis.  The availability of ALA in the cell 
cytoplasm is the rate-limiting factor in heme biosynthesis in all but erythropoetic cells.  The 
heme biosynthetic enzymes are more active in glial tumors of the brain than in normal brain 
tissue.  As a result, addition of ALA (the rate-limiting precursor) to malignant glial cells leads to 
an increase in the intracellular accumulation of Protoporphyrin IX, a fluorescent intermediary in 
heme biosynthesis.  As a result, malignant glial cells fluoresce red relative to dark normal brain 
tissue, when viewed under ultraviolet light (300 nm).  This effect enables more complete surgical 
removal of malignant glial tumor from within normal brain tissue.  
 
3.4 
Rationale for the Intraoperative Fluorescence/Reflectance Probe 
 
Although ALA results in visible concentrations of Pp IX in high grade malignant 
gliomas, detection in lower grade gliomas is limited due a relatively low intensity of 
fluorescence signals, resulting in incomplete tumor detection. However, Pp IX does accumulate 
to diagnostically significant levels in low grade gliomas even when not visibly evident to the 


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surgeon (21). To aid in the quantitative detection of subvisual concentrations of Pp IX in low 
grade gliomas, an intraoperative fluorescence/reflectance probe was custom designed under NIH 
funding. The intraoperative probe is a 1.25 mm semi-rigid, blunt end device that is placed in 
gentle contact with brain tissue by the surgeon for 3-5 seconds to make a spectroscopic 
measurement. The probe delivers a very small amount of blue light and white light to measure 
the concentration of Pp IX.  
 
The probe meets all of the criteria necessary for classification as a non-significant risk 
device according to FDA guidelines. The device is non-invasive with respect to the participant 
and does not present a serious risk to the health, safety, or welfare of a subject. The device is not 
used to diagnose, cure, mitigate, or treat disease without concordance from additional data made 
available through practices which meet or exceed standard-of-care. The light exposure levels are 
below those known to cause any temperature rise or other significant tissue damaging effects, 
even in conjunction with ALA which can be phototoxic but at much higher light exposure 
thresholds. 
 
4. 
PATIENT SELECTION 
4.1 
Eligibility Criteria 
4.1.1 Patients entering into this study will have the presumptive diagnosis of high grade or 
low grade glioma based on imaging studies, or will have recurrent high-grade or low 
grade gliomas that have previously undergone diagnosis (astrocytoma, 
oligodendroglioma, mixed oligo-astrocytoma, anaplastic astrocytoma, and 
glioblastoma multiforme).  Both of these groups will be undergoing craniotomy for 
tumor resection. 
4.1.2 Patient age 18 to 72 years. 
4.1.3 Karnofsky performance of 60% or greater, see Appendix B. 
4.1.4 Patients must have normal organ and marrow function as defined below: 
 
 
Leukocytes 
>3,000/μL 
 
Absolute neutrophil count 
 
>1,500/μL 
 
Platelets 
 
>100,000/μL 
 
Total bilirubin 
 
within normal institutional limits 
 
AST (SGOT)/ALT (SGPT) 
 
<2.5 X institutional upper limit of normal 
 
Creatinine 
 
within normal institutional limits 
 
or 
 
Creatinine clearance 
≥60 mL/min/1.73 m2 for patients with  
 
 
creatinine levels above institutional normal. 
 
4.1.5 The effects of Aminolevulinic Acid  (ALA) on the developing human fetus are 
unknown.  Therefore, women of child-bearing potential and men must agree to use 
adequate contraception (hormonal or barrier method of birth control; abstinence) prior 
to study entry and for the duration of study participation.  


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4.16 
Patient must have the ability to understand and the willingness to sign a written 
informed consent document or have a parent or guardian with the ability to understand 
and the willingness to sign the written informed consent. 
 
4.2 
Exclusion Criteria 
4.2.1 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to aminolevulinic acid (ALA). 
4.2.2 Personal or family history of Porphyrias. 
4.2.3 Uncontrolled intercurrent illness including, but not limited to ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris , cardiac 
arrhythmia, or psychiatric illness/social situations that would limit compliance with 
study requirements. 
4.2.4 Pregnancy since aminolevulinic acid (ALA) is of unknown teratogenic or abortifacient 
effects. 
 
 4.3 
Inclusion of Women and Minorities 
Both men and women and members of all ethnic groups are eligible for this study.  
 
4.4 
Study Calendar 
Baseline evaluations are conducted 3 weeks prior to start of protocol.  
 
 
Pre-
Study 
Day 
1 
Day 
2-3 
Day 14 
(+/- 5days) 
ALA a 
 
X 
 
 
Informed consent 
X 
 
 
 
Demographics 
X 
 
 
 
Medical history 
X 
 
 
 
Concurrent meds 
X 
 
 
X 
Physical exam 
X 
 
X 
X 
Vital signs 
X 
 
X 
X 
Height 
X 
 
 
 
Weight 
X 
 
 
X 
Performance Status 
X 
 
 
X 
CBC, w/diff, platelets  
X 
 
X 
X 
Serum chemistry b 
X 
 
X 
X 
EKG (as indicated) 
X 
 
 
 
Adverse event evaluation 
X 
 
X 
X 


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MRI Brain + gadolinium 
X 
 
X c 
 
B-HCG 
X d 
 
 
 
 
a:   ALA dose of 20 mg/kg oral administration one time. 
b:   Albumin, alkaline phosphatase, total bilirubin, bicarbonate,  
 
BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, 
 
potassium, total protein, SGOT(AST), SGPT (ALT), sodium. 
c: 
MRI immediately post-operation (24-48 hrs post surgery). 
d: Serum pregnancy test (women of childbearing potential). 
5 
TREATMENT PLAN 
The study will consist of 300 patients with high-grade or low-grade tumors that meet the 
eligibility criteria provided in section 4.1.  Each patient will be evaluated and found to have a 
high-grade or low-grade glioma by means of history and recent imaging studies (MRI) and 
deemed a surgical candidate based on current neurosurgical standards of care.  The study will 
have the University of California San Francisco (UCSF) ethics committee (CHR) approval.  
Informed consent will be obtained from patients meeting enrollment criteria.  The study will be 
done according to the guidelines of the International Conference on Harmonization - Good 
Clinical Practice. 
 
5.1 
Pre-surgical Procedure 
A one-time single administration of aminolevulinic acid (ALA), at a dose of 20 mg/kg 
body weight, will be given orally.  ALA will be dissolved in ~100 mL of drinking water or juice 
and given to the patient approximately 3 hours before anesthesia. 
 
5.2 
Surgical Procedure 
ALA will be mixed in the minimum volume of sterile water or juice immediately before 
use and given as a single bolus orally approximately 3 hours prior to scheduled anesthesia.  
Image-guided microsurgical resection of the tumor will be undertaken.  Following the standard 
tumor resection under light microscopy, the residual tumor bed will be illuminated with blue 
light via a high pass optical filter in the microscopes light chain.  The surgeon will examine the 
tumor bed with a barrier filter in the optical chain of the surgical microscope. The surgeon will 
quantitatively measure the concentration of Pp IX by placing the intraoperative 
fluorescence/reflectance probe in gentle contact with brain tissue by the surgeon for 3-5 seconds 
to make a recording. If fluorescence is present, and if safe, small biopsies will be taken from 
those areas of fluorescence as well as from non-fluorescing regions in the tumor resection cavity.  
When possible, the intent would be to collect a number of biopsies with a range of fluorescence 
intensities from each patient (at least one biopsy from normal-appearing tissues and at least one 
from the most fluorescent area).  All biopsy specimens, including those taken from the bulk 
tumor, will be reviewed by a neuropathologist to assess tumor content.  The expectation is that 
residual fluorescent tissue in the tumor cavity will be surgically removed (if deemed safe by the 


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neurosurgeon), potentially leading to more complete tumor resection.  Pathologic confirmation 
of tumor type will be made by neuropathology. 
Biopsies of fluorescent and non-fluorescent tissue within the tumor cavity will be graded by 
the surgeon at the time of biopsy as 0 to 3 fluorescence. A screen shot of the fluorescent image of 
the resected tumor illuminated with blue light via a high-pass filter will be documented for each 
patient with an integrating video camera.  The fluorescence intensity and the quantitative 
measurement obtained with the intraoperative probe corresponding to each area on the screen 
shot from which biopsy is taken will be recorded by the surgeon in the operating room.  The 
sample will be snap frozen in the operating room and provided to the pathologist for grading the 
tumor from 0 to 3 based on the degree of cellular infiltration.  The scale to be used for grading is 
as follows: 
 
 
Grade 
Surgeon (intensity of fluorescence) 
Pathologist (cell density) 
0 
No fluorescence 
No tumor cell density content 
1 
Mild brightness 
Mildly infiltrating tumor cell density 
2 
Moderate brightness 
Moderately infiltrating cell density 
3 
Intense brightness 
Highly infiltrating cell density 
 
The surgeon is responsible for: 
 Identifying at least one fluorescent area within the tumor cavity and performing biopsy 
and grading that site’s fluorescence. 
 Identifying at least one non-fluorescent area within the tumor cavity and performing 
biopsy and grading that site’s fluorescence. 
 Labeling the areas (i.e. fluorescent or non-fluorescent) from which the biopsies are taken. 
 
The pathologist is responsible for: 
 Grading each frozen section biopsy for tumor content on a scale of 0 to 3. 
 Labeling of specimens to be certain they correlate with biopsies taken by the surgeon. 
 
5.3 
Extent of Resection Follow-up 
Patients will be assessed for completeness of tumor resection immediately following 
surgery (within 24 to 48 hours) using gadolinium enhanced brain MRI.  Extent of resection will 
be assessed based on the finding of postoperative enhancement or lack of enhancement, on the 
postoperative imaging scans and will be evaluated as follows: 
 Complete Resection (GTR): Resection of all enhancing disease 
 Partial Resection (STR): At least a 50-90% decrease in the sum of the longest 
diameter (LD) of enhancing disease, taking as reference the baseline pre-operative 
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 Near Complete Resection: Between a 90 and 99% resection of enhancing disease 
 Minor Resection: All other situations (< 50% removal) 
 
5.4 
Supportive Care 
Patients will be managed according to procedures for standard care established for 
postoperative brain resection patients.  The patient will be kept in a "low light" environment for 
72 hours following administration of ALA. 
6 
REGULATORY AND REPORTING REQUIREMENTS 
6. 1   UCSF Data Safety Monitoring Plan for Phase II or III Institutional Study  
 
Oversight and Monitoring Plan 
 
The UCSF-CCC Data Safety Monitoring Committee (DSMC) is responsible for 
monitoring data quality and patient safety for all UCSF-CCC institutional clinical studies.  A 
summary of DSMC activities for this study includes:  
 
 Review of subject data in each cohort  
 Quarterly review for progress and safety 
 Review of all serious adverse events  
 Minimum of a yearly audit  
 
6.2 
Monitoring and Reporting Guidelines 
 
Investigators will conduct continuous review of data and patient safety at monthly study 
group or site committee meetings where the results of each patient’s treatment are discussed and 
the discussion is documented in the minutes.  The discussion will include the number of patients, 
significant toxicities as described in the protocol, doses adjustments, and observed responses.  
Quarterly summaries will be submitted to the DSMC for review.  All grade 3-5 AE’s and SAE’s 
will be entered in the CCC Oncore database.   
 
6.3 
Review and Oversight Requirements 
 
6.3.1 Adverse Event Monitoring  
 
Adverse Events (AEs) will be recorded on the Oncore database, all grade 3-5 expected 
and unexpected AEs will be recorded and updated at each visit. 
 
6.3.1.1 Serious Adverse Event Reporting  


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Serious Adverse Event reporting will be in accordance with the UCSF- Committee on 
Human Research Regulations and Code of Federal Regulation Title 21 Volume 5 Part 312.32. 
 
UCSF CHR website for guidance in reporting serious adverse events 
http://www.research.ucsf.edu/chr/Guide/Adverse_Events_Guidelines.pdf 
  
 
FDA website for guidance in reporting serious adverse events  
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=312.32 
 
MedWatch forms and information:  
http://www.fda.gov/medwatch/getforms.htm 
 
 
Serious Adverse events will be reported on the MedWatch form.  A copy of the 
MedWatch report and CHR forms must be sent to CCC- DSMC at Box 1297.  The date the SAE 
was sent to all required reporting agencies will be documented and one Oncore, hard copies of 
the report will be maintained in the regulatory files. 
 
If the SAE is death and determined to be possibly, probably or definitely related to 
the investigational drug or any research related procedure, the event must be reported to 
the DSMC Chair or his designee within 24 business hours.  The reporting procedure is by 
personal communication via phone or in person with written documentation of the 1:1 
communication via e-mail with a copy of the e-mail to DSMC Administrator and DSMC 
Coordinator. 
 
6.3.2 Review of Adverse Event Rates 
 
If the study has an increase of unexpected or expected Adverse Events, grade 3 or 4 
above the rate reported in the Investigational Brochure or package insert, the increase rate of AEs 
will be reported to the DSMC at the time of Identification.  The Chair and PI will discuss the 
finding and proceed with a written course of action.  Each quarterly report will indicate if the AE 
incidence is within the scope of the investigational brochure or package insert.  If at any time the 
Investigator stops enrollment or stops the study due to safety issues, the DSMC Chair and 
Administrator must be notified within 24 business hours via e-mail.  The DSMC must receive a 
formal letter within 10 business days and the CHR must be notified. 
 
6.3.3 Study Progress – Quarterly Review 
 
Principal Investigators are required to submit quarterly study progress reports to 
determine whether accrual projections are being met, to summarize grade 3 and 4 toxicities 
(expected and unexpected) and SAE reports.  This report will also indicate if the rate of all grade 


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3-5 AE’s are above the AE rates documented in the Investigational Brochure or package insert.  
In addition, a progress report on recruitment and subjects known responses to the investigational 
therapy must be submitted.  At this time also send the committee all external DSMB reports and 
formal audit reports. 
 
These quarterly reports are reviewed at Data Safety Monitoring Committee meetings.  
These reports are required:  February 1, May 1, August 1, and October 1.  Failure to submit such 
reports may result in trial suspension.  Send reports to: DSMC Box 1297 
 
 
Data Safety Monitoring Committee Contacts: 
DSMC Chair:  Alan Venook, MD 
Phone  
(415) 353-2745 
Email  
venook@cc.ucsf.edu 
Box 
 
1705 
 
 
6.4 
Adverse Event Reporting 
An adverse event is any untoward medical occurrence in a patient administered a 
pharmaceutical product, which does not necessarily have a causal relationship with the treatment.  
An adverse event can be any unfavorable and unintended sign (e.g. including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of the drug, whether 
or not it is considered to be drug related.  This includes any newly occurring event or previous 
condition that has increased in severity or frequency since the administration of the drug. 
A serious adverse event (SAE) is any adverse event, occurring at any dose and regardless 
of causality that: 
 is fatal 
 life-threatening  Life -threatening means that the patient was at immediate risk of 
death from a reaction as it occurred (i.e., does not include a reaction which 
hypothetically might have caused death had it occurred) 
 requires inpatient hospitalization or prolongation of existing hospitalization 
 results in persistent or significant disability/incapacity 
 is a congenital anomaly/birth defect 
 is an important medical event, which is defined as an event that may not result in 
death, be life-threatening, or require hospitalization but may be considered an 
SAE when, based upon appropriate medical judgment, it may jeopardize the 
patient and may require medical or surgical intervention to prevent a SAE. 
 
Since potential adverse events related to ALA are known to be transient in nature, it is 
felt that a 14-day evaluation window is relevant to assess the safety profile of this agent. All 
adverse events will be collected from the time of drug administration and will continue to be 
collected until 14 days (+/- 3days) from the time of drug dosing. In addition, serious adverse 
events (SAE) will be collected beginning from the time the subject signs the informed consent. 


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The descriptions and grading scales found in NCI Common Terminology Criteria for adverse 
events (CTCAE) version 3.0 will be utilized for adverse event reporting and are available on line 
http://ctep.cancer.gov/reporting/ctc.html. SAEs and expedited reporting of specific expected 
AEs will be submitted to the FDA via the FDA safety information and adverse event reporting 
system MedWatch, FDA form 3500A. 
  
6.4.1 Probable ALA adverse events to be expected 
Transient side effects have been noted, most commonly, skin photosensitivity, nausea, vomiting, 
abdominal discomfort, and lowering of blood pressure which can result in lightheadedness.  
Since ALA may cause nausea and vomiting, patients will be monitored and treated as needed 
with anti-nausea medication. 
Dose-dependent abnormalities in liver function tests have been documented.  The most 
common effect has been a rise in transaminases (typically AST), (23-29).  Liver function tests 
AST and ALT will be performed throughout the study, please see the Study calendar provided in 
section 4.4. 
ALA-induced Pp IX accumulation occurs predominantly in cells of epithelial origin and 
isolated cases of skin photosensitivity with subsequent cutaneous injury after sun/bright light 
exposure have been reported (29, 30).  Skin reactions in clinical photodynamic therapy trials with 
doses of 30-60 mg/kg have been mild, consisting primarily of erythema that resolved within 24 
to 48 hours.  Blister formation and/or skin necrosis have not been reported in these trials and 
neither have any indications of ocular sensitivity been described with systemic ALA.  
Precautions will be taken to protect the patient from the effects of skin photosensitivity during 
surgery.  Patients will receive instructions on how to protect themselves and to minimize 
exposure to sunlight and/or indoor lighting for up to 72 hours.  Patients with a history of 
cutaneous photosensitivity, porphyria, hypersensitivity to porphyrins, photodermatosis, 
exfoliative dermatitis or an inability to comply with the photosensitivity precautions associated 
with the study will be excluded from enrollment. 
The light dose (due to fluorescence excitation) to the brain during fluorescence image-
guided resection can be estimated to be approximately 216 J.cm-2, based on data presented in 
Stummer (11), an irradiance of ~60mW.cm-2, and an approximate illumination time of 1 hour.  
The risk of complications due to a potential PDT effect are considered minimal since no serious 
adverse events were reported by Stummer (11, 14), the ALA dose in our trial (20 mg/kg) is equal 
to that used in these studies and is lower than the ALA doses used for PDT which typically reach 
60mg/kg (12, 23-28, 30-38). 
 
6.4.2 Other possible adverse events 
The following more serious expected adverse events that could occur in this study 
protocol will not require expedited reporting, but the event will be captured in the patient's study 
file. 
 Reaction to anesthesia. 
 Balance problem as the results of the tumor itself or from the surgery to correct it. 


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 Bleeding which may occur as the result of the surgery or from medications. 
 Blood clot development, which may occur with any surgery. 
 Brain injury that could happen depending on the location of the tumor and 
removal procedure. 
 Cardiac complications since there is a chance the procedure could cause an 
irregular heartbeat or heart attack. 
 Functional loss as there is a possibility of experiencing problems such as opening 
the mouth, chewing, speech, language, and memory difficulties following surgery. 
 Hydrocephalus as it is possible that the normal flow of spinal fluid around the 
brain may be altered. 
 Infection that may occur at the incision site and may also occur within the bone 
flap. Infection-related risks also include meningitis or a brain abscess. 
 Loss of nerve function or paralysis. 
 Post-operative pain such as a headache that may persist for a week to a month and 
sometimes for a longer time period. 
 Recurrence of the tumor may return to the same site. 
 Respiratory difficulties, which could include breathing difficulties, post-operative 
pneumonia or a pulmonary embolus. 
 Seizure activity. 
 Visual disturbance. 
 
6.5 
Environmental Assessment 
A claim is made for categorical exclusion under 21 CFR 25.31 (e) for this IND.  The use 
of ALA is not considered toxic and the standard procedure for chemotherapy waste disposal will 
followed. 
7 
STATISTICAL CONSIDERATIONS  
7.1 
Study Endpoints 
This is a single-center, single arm, open label phase II trial of fluorescence-guided 
resection by use of 5-aminolevulinic (ALA) at a dose of 20 mg/kg body weight in glioma 
patients.  We hypothesize that surgical removal of the residual fluorescent tissues in the tumor 
cavity, presumably representing tumorous cells, will result in an increase in the amount of tumor 
removal during neurosurgical resection.  In addition, we hypothesize that for recurrent malignant 
glioma, that the fluorescent material will reflect active viable tumor and not changes related to 
treatment such as macrophages or gliosis. 
The primary analysis will be based on one biopsy taken from the most fluorescent area 
and one from normal appearing tissues for each patient as judged by the neurosurgeon. 
The endpoints of interest in this study are as follows: 


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 Primary Endpoint: Positive Predictive Value (PPV), defined as the percentage of biopsies 
taken from the most fluorescent tissues determined by the pathologist as having tumorous 
content. 
 Second Endpoints:  
o  Negative Predictive Value (NPV), defined as the percentage of biopsies taken 
from non-fluorescent tissues determined as having no tumor content by the 
pathologist. 
o The safety of the use of 5-aminolevulinic (ALA) at a dose of 20 mg/kg body 
weight for neurosurgical resection in glioma patients 
o The correlation between fluorescent intensity as scored by the neurosurgeon and 
the tumor content as scored by the pathologist 
o The percentage of patients for whom there is no fluorescent tissue after surgery 
 
7.2 
Sample Size Determination 
There is interest in assessing the correlation of 5-ALA uptake and degree of fluorescence 
among the different grades and histological subtypes of newly diagnosed high- and low- grade 
glioma. In addition, once a high-and low- grade glioma has been treated with radiation and 
chemotherapy, it is well accepted that treatment related changes can be seen histologically. There 
has been little experience in the assessment of the use of 5-ALA in the recurrent setting and in 
this study we are interested in the specificity of 5-ALA uptake in tumor cells in the post treated 
setting. As such, in addition to newly diagnosed glioma patients, there will be a specific 
subgroup of recurrent glioma who will be studied. 
The patients will be allocated to the following subgroups: 
1) Newly diagnosed GBM   
2) Newly diagnosed grade III glioma (astrocytic, oligodendroglial and mixed)  
3) Recurrent GBM   
4) Recurrent grade III glioma (astrocytic, oligodendroglial and mixed) 
5) Newly diagnosed low grade glioma (astrocytic, oligodendroglial, ganglioglial, 
and mixed) 
6) Recurrent low grade glioma (astrocytic, oligodendroglial, ganglioglial, and 
mixed) 
 
A total of 50 patients per subgroup will be enrolled. The main goal is to determine the 
intraoperative detection of malignant and low grade glioma by the use of 5-aminolevulinic 
(ALA), as measured by PPV defined above. In order for this agent to be useful, we would expect 
PPV to be at least 80%. Therefore, 80% is considered the lower threshold for the hypothesis 
testing (i.e. under H0). The calculation of sample size was based on a targeted PPV of 92%. Fifty 
patients per cohort will provide approximately 90% power to detect this improvement using a 
one-sided exact binomial test with alpha of 0.10. The agent will be deemed useful if 44 or more 
biopsies taken from the most fluorescent tissues are determined by the pathologist as having 
tumorous content. 


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 7.3 
Statistical Analysis 
The primary analysis will include all patients who are eligible for this study and who 
undergo planned neurosurgery. PPV and NPV will be estimated and the 95% confidence interval 
associated with each measure will be provided.  Secondary analysis will take advantage of 
multiple biopsies taken from areas representing a range of fluorescence intensity within each 
patient.  The Spearman’s rank correlation coefficient will be calculated to assess the correlation 
between fluorescent intensity as scored by the neurosurgeon and the tumor content as scored by 
the pathologist.  To account for within-patient correlation, the Cochran-Mantel-Haenszel Chi-
Squared test will be used to test the association between fluorescence intensity and tumor 
content. 
All patients who are enrolled and take 5-ALA will be considered evaluable for toxicity.  Since 
potential adverse events related to 5-ALA are known to be transient in nature, it is felt that a 14-
day evaluation window is relevant to assess the safety profile of this agent.  The formal analysis 
and final report of toxicities will be performed when all patients have been enrolled and followed 
for toxicities for 14 days after administration of 5-ALA.  Reporting of adverse events is 
described in Section 6.  We intend to monitor adverse events on a monthly basis to determine if 
there are unacceptable toxicities.  A report of all adverse events since the first subject was 
enrolled will be prepared every month, along with a tabular display of the relative frequency of 
all grade 2 or higher toxicities considered possibly, probably, or likely related to 5-ALA.  This 
information will be submitted to the UCSF-CCC Data Safety Monitoring Committee (DSMC) 
who is responsible for monitoring data quality and patient safety for all UCSF-CCC institutional 
clinical studies. 
 


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8 
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