Survival Experience Following Nd:YAG Laser Photoresection for Primary Bronchogenic Carcinoma: Discussion
Forty-seven consecutive patients with inoperable primary bronchogenic carcinoma underwent palliative YPR over a period of 36 months for exophytic obstructive symptomatic endobronchial lesions. The primary goal of therapy was palliation, and YPR was successful in the immediate relief of obstructive symptoms in all patients. We have shown a statistically significant increase in survival in the 15 patients undergoing emergency YPR compared with the 11 patients who underwent emergency palliative XRT alone when YPR was not yet available. While the median survival of 267 days for the patients undergoing emergency YPR is less than the median survival of 304 days for the whole group (n = 35) and of 312 days for patients already treated with XRT (n = 20), it is quite an increase over patients receiving emergency XRT (median survival, 150 days). This does not suggest that YPR is superior to XRT for all patients, but that patients with critical obstructive lesions fare relatively poorly when treated with XRT alone.
A trend toward increased survival was demonstrated in patients who underwent EB-XRT + XRT + YPR (median survival, 471 days) as compared to patients undergoing XRT + YPR (median survival, 304 days). The total number of patients undergoing additional endobronchial radiation therapy was too small to show statistical significance, but future studies with more patients may show an increased survival with EB-XRT.
For comparative analytic purposes, we established a control group of inoperable patients with primary bronchogenic carcinoma who underwent palliative XRT between 1981 and 1983, when YPR was not yet available at the Cleveland Clinic Foundation. Such analytic methods were also utilized by Brutinel et al in their two-year experience with Nd:YAG laser in endobronchial obstruction. To limit the bias of using historic controls, we analyzed the patients in our control group as well as the patients who underwent YPR both according to their cell type and by the presence or absence of metastases. In our study, we were not able to show a significant increase in overall survival in patients treated with XRT + YPR vs patients treated with XRT alone within various cell types or the presence or absence of metastatic disease. Eichen-horn et al showed an increased survival (median survival, 340 days) with laser photoresection greater than that provided by historic controls using irradiation alone.
Since we could show no significant increase in overall survival with YPR, we agree with Eichenhorn et al and Joyner et al that a randomized trial comparing Nd:YAG laser photoresection with XRT vs XRT alone is warranted, but patients with critical lesions producing massive hemoptysis or asphyxiation in whom we have shown an improved survival with YPR followed by XRT vs XRT alone should not be included. We agree with McDougall and Cortese that YPR offers not only symptomatic relief of critical airway lesions associated with dyspnea, asphyxia, or hemoptysis, but that an increased survival rate may also be achieved.