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The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis Weller, M.D.,* Nankivell, P.C.,* McConkey, C., † Paleri, V. ‡ & Mehanna, H.M.* *Institute of Head and Neck Studies and Education, University Hospitals Coventry and Warwickshire, Coventry, UK, Clinical Trials Unit, University of Warwick, Coventry, UK, and Freeman Hospital, Newcastle upon Tyne, UK

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Accepted for publication 15 July 2010 Clin. Otolaryngol . 2010, 35 , 364–372

Results: Nine hundred and forty cases from nine studies were included in the analysis. Overall malignant transfor mation rate was 14% (confidence interval 8, 22) and mean time to malignant transformation was 5.8 years. The malignant transformation rate is higher with increased severity of dysplasia grade – severe ⁄ CIS 30.4% versus mild ⁄ moderate 10.6% ( P < 0.0002). Treatment modality did not show significant effects. Conclusions: Laryngeal dysplasia carries a significant risk of malignant transformation. This risk triples with increasing severity of dysplasia. Transformation often occurs late and is not related to the grade of dysplasia. There is little evidence, therefore, to support the early dis charge of patients with mild ⁄ moderate dysplasia, which is practised by some clinicians. laser. 5 Repeated surgical intervention for recurrent lesions can lead to significant vocal cord scarring and vocal mor bidity. Non-surgical options such as radiotherapy may be used in widespread or refractory lesions. Radiotherapy carries well-documented morbidities such as dry mouth and alteration of voice. The management and follow-up strategies of these lesions vary widely, from a simple biopsy 6–9 to exclude malignancy through to repeated resection 10 or radio therapy, 11 and from a single postoperative visit to lifelong follow-up. A recent national survey by ENT-UK demon strated the lack of consensus in managing laryngeal dys plasia in the UK, 12 and acknowledged that there is a considerable lack of evidence regarding the natural his tory of this condition, the optimum management and best follow-up strategies. In order to develop an evidence based surveillance policy for laryngeal dysplasia, we undertook a systematic review and meta-analysis to assess the risk of and interval

Background: Laryngeal dysplasia is a pre-malignant con dition with wide variability in rates of malignant transfor mation reported in the literature. The management and follow-up strategies of these lesions vary widely. Objectives: To assess the risk of and interval to malig nant transformation in patients with laryngeal dysplasia, the effect of different treatment modalities on malignant transformation and the effects that risk factors such as smoking, excessive alcohol intake and histological grade may have on this. Type of review: Systematic of observational studies with attempted meta-analysis. Search strategy: A structured search of Medline (1966 to January 2010), EMBASE (1980 to January 2010), CI NAHL (1981 to January 2010) and Cochrane databases (CENTRAL, Cochrane Library, 1995 to January 2010). Laryngeal dysplasia is a pre-malignant condition with between 2 and 10 lesions reported per 100 000 of the population. 1 It refers to an abnormality in maturation of cells within the larynx, and carries the potential to progress to invasive cancer. Malignant transformation rates (MTR) have been reported to be between 2% 2 and 74% 3 of cases. This may reflect the case mix of these studies – as the more severe the dysplasia, the higher the rate of transformation. Additionally, the inter- and intra-rater reliability of grading dysplastic lesions varies greatly. 4 The main treatment modality is surgical excision, which is performed with cold steel instruments or CO 2

Correspondence: Mr. Hisham Mehanna, Director and Honorary Associate Clinical Professor, Institute of Head and Neck Studies and Education, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, UK. Tel.: 02476 965244; Fax: 02476 966915; e-mail: hisham.mehanna@uhcw.nhs.uk

2010 Blackwell Publishing Ltd • Clinical Otolaryngology 35, 364–372

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