Tachosil for the Prevention of Symptomatic Lymph Cysts
Condition: Endometrial Cancer; Cervical Cancer
MeSH terms: Endometrial Neoplasms
Study type: Interventional
Phase: Phase 3

Summary: 
      This is a randomized trial of 140 women with endometrial or cervical cancer undergoing
      removal of lymph tissue (lymphadenectomy). The application of 4 tachosil fibrin patches to
      the pelvic side wall after tissue removal is tested against no such intervention after tissue
      removal. The primary endpoint is to evaluate the incidence of symptomatic pelvic lymphoceles
      defined by CTCAE 4.03 grade >2 within 4 weeks after surgery in women undergoing open or
      laparoscopic pelvic lymphadenectomy for cervical and endometrial cancer with and without the
      application of Tachosil® during surgery. The study's hypothesis is that the application of
      tachosil fibrin patches will significantly reduce the rate of symptomatic lymph cysts.
    

Detailed description: 
      1. Background Women with gynecologic malignancies such as cervical and endometrial cancer
      routinely undergo pelvic lymphadenectomy based on tumor characteristics assessed prior to or
      during surgery. Pelvic lymphadenectomy may be performed by open surgery or laparoscopy (1-4).
      Postoperative complications during and after pelvic lymphadenectomy include local abscess,
      bleeding, lymphocele, and chronic lymphedema of the lower extremities, which has an incidence
      of 1 to 2% (2,3). In the present trial, we will focus on pelvic lymphoceles, one of the most
      common complications of pelvic lymphadenectomy. Simonato et al. described a rate of 19/30
      (63%) of sonographically detected lymphoceles in men undergoing pelvic extraperitoneal
      lymphadenectomy for prostate cancer (4). In this trial, 4/19 men with lymphoceles were
      symptomatic and required medical interventions. In women with cervical cancer, asymptomatic
      lymphoceles detected by ultrasound have been noted in up to 11% of women after pelvic
      lymphadenectomy (1,3,5). In 2% of women, clinical symptoms will require a therapeutic
      intervention (5).

      Tachosil® is a fibrin-collagen coated patch and heas been licensed in 2004 and 2007 in Europe
      for surgical use in humans to support surgical hemostatic interventions. The efficacy and
      safety of Tachosil® has been demonstrated in liver resection, pulmonary lobectomy, and kidney
      tumor resection trials (6-8). In men, but not in women, it has been demonstrated that the
      application of a collagen-fibrin patch to the lymphadenectomy surgery site may prevent a
      significant proportion of lymphoceles. In a randomized trial, Simonato et al. found that the
      pelvic application of two Tachosil® patches to the obturator fossa and the femoral canal was
      sufficient to significantly reduce the rate of sonographically detected lymphoceles within 4
      weeks after surgery from 19/30 to 5/30 cases (p=0.001) as well as the mean drainage volume
      from 190 to 64 ml. Percutaneous puncture of a symptomatic lymphocele was necessary in 1/30
      individuals in the intervention group compared to 4/30 individuals in the control group. (4).
      In women with gynecologic malignancies a single center randomized controlled trial has found,
      that Tachosil® seems effective to reduce the rate of lymphoceles after pelvic lymphadenectomy
      (5). 7/30 (23.3%) women in the treatment group compared to 9/28 (57.7%) women in the control
      group developed asymptomatic lymphoceles (p<0.05) (5). No significant differences between the
      two groups were observed in the development of symptomatic lymphoceles or the rate of
      interventions (5). This may be attributable to the small sample size of this study. As
      symptomatic lymphoceles are more relevant for the patient, it seems clinically more important
      to the evaluate the impact of Tachosil® on the rate of symptomatic lymphoceles after pelvic
      lymphadenectomy.

      Symptomatic lymphoceles are defined by the CTCA 4.03 grading system as lymphoceles grade >2.
      This includes all lymphoceles needing medical intervention. Thus this definition comprises,
      lymphoceles with the presence of localized pelvic pain, pelvic abscess, fever, and/or leg
      edema in the presence of a sonographically verified pelvic lymphocele.

      In summary, the data available in the literature demonstrate that pelvic lymphocles occur in
      11 to 63% of individuals undergoing pelvic lymphadenectomy. Symptomatic lymphoceles seem to
      occur in about 32% of patients undergoing pelvic lymphadenectomy. Intraoperative application
      of a collagen-fibrin patch may reduce the number of lymphoceles, mean drainage volume, and
      the necessity of medical interventions such as percutaneous puncture.

      Therefore, we intend to perform a multi center randomized clinical trial assessing the
      efficacy of a collagen-fibrin patch for preventing symptomatic lymphoceles in women
      undergoing pelvic lymphadenectomy for gynecologic malignancies, ie cervical and endometrial
      cancer. We hypothesize that, based on the data of Simonato et al. and Tinelli et al., the
      application of a collagen-fibrin patch (Tachosil®) will reduce the number of symptomatic
      pelvic lymphoceles by at least 66%.

      Primary outcome variable:

      2.1. To evaluate the incidence of symptomatic pelvic lymphoceles defined by CTCAE 4.03 grade
      >2 within 4 weeks after surgery in women undergoing open or laparoscopic pelvic
      lymphadenectomy for cervical and endometrial cancer with and without the application of
      Tachosil® during surgery.

      Secondary outcome variables:

      2.2. To evaluate the incidence of sonographically detected pelvic lymphoceles of at least 2cm
      in the largest diameter 4 weeks after surgery in women undergoing open or laparoscopic pelvic
      lymphadenectomy for cervical and endometrial cancer with and without the application of
      Tachosil® during surgery.

      2.3. To evaluate the rate and type of medical interventions for clinically symptomatic pelvic
      lymphoceles such as analgesics and/or lymphocele puncture and drainage.

      3. Study Hypothesis We hypothesize that the intraoperative application of two collagen-fibrin
      patches (Tachosil®) to the obturator fossa and the femoral canal will reduce the number of
      symptomatic pelvic lymphoceles by at least 66% (primary study end point).

      4. Study Design Prospective randomized clinical intervention trial of 140 women undergoing
      open or laparoscopic pelvic lymphadenectomy for cervical or endometrial cancer. Randomization
      will be by a computerized randomization list. Women will be centrally randomized by the
      principal investigator (CT). Allocation will be communicated by telephone after informed
      consent has been obtained and after lymphadenectomy has been completed. This is a
      single-blinded study, ie patients, but not surgeons, will be blinded to the treatment
      allocation. Outcome assessment will not be performed by the surgeon, who has performed the
      lymphadenectomy. Outcome assessors will be blinded to the treatment allocation.

      5. Treatment

      All women will undergo open or laparoscopic surgery. Within this procedure, as deemed
      appropriate by the surgeon, women will undergo pelvic lymphadenectomy. The procedure will be
      performed as follows:

      The peritoneum will be incised parallel to the iliac vessels. Then, the iliac vessels will be
      screened for the presence of bulky lymph nodes. If a lymph node debulking is performed, no
      patch will be applied. In women who undergo routine pelvic lymphadenectomy, lymph node tissue
      will be removed from the external iliac vessels, the obturator fossa, the interiliac region,
      and the common iliac region after identification and appropriate preparation of surgical
      landmarks, ie iliac vessels, femoral canal, chorda, and obturator nerve. At the end of the
      procedure, hemostasis will be checked. A Tachosil® patch of 4.8x4.8cm will be attached to the
      obturator fossa and a Tachosil® patch of 4.8x4.8cm will be attached to the femoral canal of
      each side of surgery in the intervention group. In the control group, no Tachosil® patch will
      be used. No specific drainage of the retroperitoneum will be performed. All surgical
      procedures will be performed by the study team members Clemens Tempfer, Lukas Hefler, and
      Alexander Reinthaller, experienced in open and laparoscopic pelvic lymph node dissection. In
      order to ensure adequate application of the Tachosil® patch by laparoscopy, all surgeons will
      perform at least two laparoscopic training operations during which they roll the Tachosil®
      patch around a laparoscopic instrument, move it through a 10mm trocar into the abdomen, and
      flatten it out.

      8. Statistical analysis A power calculation demonstrated that, with a sample size of 70 per
      group, a two-arm study has a power of 80% to detect a 66% absolute difference in treatment
      efficacy at a significance level of 0.05 regarding the primary outcome parameter, ie
      symptomatic lymphoceles CTCAE 4.03 grade >2. This calculation was based on published data by
      Tinelli et al. observing a rate of 32% of symptomatic lymphoceles in the placebo group and
      10% in the Tachosil® group (5). Assuming a 10% drop out-rate, 140 women will be randomized.
      The chi-square test will used for comparisons of frequencies and cross-tabulations. One Way
      ANOVA on ranks will be used on means. Descriptive statistics (means, standard deviations, and
      ranges) will be used for demographic data. Bonferroni's correction will be used for multiple
      comparisons of secondary outcomes.

      10. Follow-up All women will undergo a gynecologic examination and a transvaginal and
      transabdominal ultrasound examination at the time of discharge of the hospital, performed by
      a physician experienced in transvaginal and transabdominal ultrasound examinations, who has
      not participated in the original surgical procedure and is blinded to the treatment
      allocation. All women will be scheduled for a follow-up visit 4 weeks after surgery including
      a gynecologic examination and a transvaginal and transabdominal ultrasound examination,
      performed by a physician experienced in transvaginal and transabdominal ultrasound
      examinations, who has not participated in the original surgical procedure and is blinded to
      the treatment allocation.
    

Intervention name(s): Tachosil fibrin patch
Intervention type(s): Drug
Intervention description(s): A Tachosil® patch of 4.8x4.8cm will be attached to the obturator fossa and a Tachosil® patch of 4.8x4.8cm will be attached to the femoral canal of each side of surgery in the intervention group. In the control group, no Tachosil® patch will be used. No specific drainage of the retroperitoneum will be performed.
Other intervention name(s): EU registration number: EU/1/04/277/002
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Prevention
Keywords: lymph cyst; lymphocele; fibrin; collagen; prevention; cancer