MELAMAG Trial: SentiMAG Melanoma - Sentinel Node Biopsy using Magnetic Nanoparticles: A prospective multicentre feasibility non-randomised clinical trial to compare sentinel node biopsy using magnetic nanoparticles vs. standard technique.

The MelaMag Multicentre Trial is a continuation of two earlier conducted
studies (see section 1.3 and 1.4 in protocol). The initial clinical pilot study
was conducted by Chief Investigator, Mr Michael Douek, at University College
Hospital. Ten patients with newly diagnosed breast cancer scheduled for
sentinel node biopsy were recruited prior to surgery. These patients received a
radioisotope injection and underwent lymphoscintigraphy a day prior to surgery.
On the morning of surgery, they received a subcutaneous injection of a SPIO
tracer (Endorem, Guerbet, Paris) in the MRI Department. Dynamic axillary MRI
before and after injection of the SPIO identified lymphatic tracts and sentinel
nodes in 5/6 patients (1scan failed for technical reasons). Under general
anaesthetic, patients routinely received an intradermal injection of patent
blue dye (Guerbet, Paris). The sentinel node(s) were localised using both a
gamma-probe and magnetometer prototype I. Skin localisation with magnetometer
prototype I and the gamma probe, were identical. A total of 19 sentinel nodes
were resected from 9 patients. Intra-operative localisation using the combined
technique was succesful in detecting 19/19 (100%) nodes and using magnetometer
prototype I alone in 19/19 (100%). Once found by the surgeon, most sentinel
nodes were easily identified as black from SPIO deposition.

Following the initial pilot study, several challenges were identified,
including interference from large metal objects, the shape of the probe and the
stability of the magnetic field. These were rectified and a second prototype
was developed (prototype II). The Chief Investigator relocated to Guy's
Hospital and a further 43 patients were recruited into an extended phaase I/II
trial. The overall ex-vivo SentiMag Multicentre SLN detection rate was 86%
(37/43 patients) and was higher in patients who received SPIO more than one
hour prior to surgery (93%, 14/15 patients). Data on the laboratory performance
of the CE-marked SentiMag and prototype II, were comparable and was included in
the application for CE approval. The first sentinel node biopsy using the
CE-marked SentiMag was performed succesfully on the 6th December 2010. The
phase II trial in which 176 breast cancer patients were included in 6 hospitals
(5 in the UK and 1 in Holland - MST, Enschede) are now working on publishing.
Following the results of the phase II trial in breast cancer patients, a METC
application is written for the same technique (Sienna+ and SentiMag). Ethics
Committee approval to commence a phase II clinical trial at Guy's Hospital has
already been granted.

The principal objective of the study is to determine if the performance of the
new technique (magnetic tracer and magnetometer) is equivalent to the
performance of the standard technique (patent blue dye and radioistope; or
radioisotope alone).

The primary objective of the MRI is to localize the SLN, the secundary
objective of the MRI and the ex-vivo MRI is to determine if MRI can be used as
an non-invasive method for identification of melanoma metastasis in lymph
nodes.

The MelaMag Mutlicenter Trial is a phase II paired equivalence trial. It will
initially involve 6 centres and will be coordinated from King's College London
(Guy's Hospital) by the Chief Investigator. The trial aimed to recruit 160
patients. Centres will be invited to recruit 30 patients and the trial will be
closed once the target number of 160 complete patient datasets has been
reached.

Patients will receive a radioisotope injection and a intradermal injection of
Sienna+ close to the tumour. This may be given between up to thirty minutes
before surgery. In centres that also participate in the MRI subprotocol,
patients will undergo a pre-operative MRI before and after the injection of
Sienna+. Ath the Medisch Spectrum Twente pre-operative MRI scans will be
performed depending on the availability of the MRI scanning slots.

Intra-operatively, patients will receive an intradermal injection of patent
blue (Guerbet, Parijs). All sentinel nodes detected intra-operatively using
either the gamma probe or SentiMag; or demonstrating blue or black staining
will be excised. In the lead centre (and any other sites participating in the
MRI subprotocol), ex-vivo MRI scans of the excised nodes will be undertaken
using a high-resolution MRI scanner. In the Medisch Spectrum Twente an ex-vivo
MRI scan of the excised nodes is not possible. At the University of Twente in
Enschede the amount of iron in each excised node will be measured using a
quantitative magnetometer.

All lymph nodes will be assessed histologically and the nodal status will be
related back to the SLNB detection rate with each technique.

Patients will be followed post-operatively as per local protocol (7-14 days)
and to assess if staining occurs or for any other adverse event. If staining is
present, photographs will be taken. To capture 30 days outcome a follow-up CRF
needs to be completed, this can be done by telephone call. Further follow-up
is at 3 months and at 1 year. Patients will be followed up for a total of 5
years, in accordance with current local policies.

The Medisch Spectrum Twente will participate in the MRI subprotocol. As part of
the MRI subprotocol, patients will undergo an MRI scan prior to the scheduled
operation. The scan will take roughly 60 minutes and involves lying down in a
tubular scanner. Once positioned in the scanner, an initial scan will be
undertaken. Following the initial scan, a intradermal injection of 0,5-2 mL
Sienna+ near the tumour is given and a second scan is performed. The scan may
need to be repeated at 2 hours after the initial scan but further injections
will not be required.

The operation will be performed as already planned by the surgeon. In addition
to the normal patent blue dye and radioactive injection, an additional
injection of Sienna+ is administered close to the tumour (an additional Sienna+
injection is only required if the MRI was undertaken over 24 hours prior to
surgery). During surgery, the sentinel nodes will be detected with the normal
detector (gamma probe), the magnetometer (SentiMag) and visually (blue and
black-brown colour). The detected nodes will be excised and are taken to the
University of Twente for quantitative magnetometer measurements. After the
measurement the lymph nodes are send to the histopathology laboratory for
analysis. The analysis in the laboratory is performed routinely and does not
form part of this study.

There is a risk of tattooing of the skin following injection of Sienna+.
However, this is a prevalent problem with the use of blue dye and not with the
use of a magnetic tracer. In the previous SentiMag studies (section 1.3 and 1.4
in the protocol), we used a magnetic dye that is similar to Sienna+, called
Endorem. Injection of Endorem resulted in minimal skin discolouration in only 6
out of 51 patients.

A potential risk factor might be the chance of developing adverse reactions to
Sienna+. However, the available evidence on the use of similar materials to
Sienna+ (for example Resovist, when only 1% of the patients developed adverse
reactions to intravenous injection of the dye in much higher concentrations)
and the CE-marking of Sienna+ show that there are no additional risks to
participants other than discolouration/ staining noted previously with Endorem.

Sienna+ has been revieuwed and tested as specified in EN 10993-1:2009 based on
the specified site of injection and showed no serious reaction after injection.