FLEX October 2023
370 M.D. Weller et al.
disease site of interest, were cross-sectional in methodol ogy or did not report specifically on dysplasia. This left only nine studies from which data could potentially be extracted. The quality of studies was mainly poor to moderate with very few prospective studies. Furthermore, the systematic review meta-analysed published data, rather than original patient data. It was not always possi ble to extract complete data from each paper, as is shown in Tables 1 and 2. Every effort was made to contact the authors for their original data, but this was not forthcom ing in most cases. There was also a variation in the methodology used in the studies, particularly with regard to patient man agement and follow-up, and in the data that was col lected, such as patient demographics and risk factors. Smoking for example, which is one of the main risk factors, was very poorly reported among the studies. This may have a significant effect on the reported transformation rates. Furthermore, these nine studies were quite heterogeneous implying that they may be measuring different aspects of the disease. However, there was no evidence of significant publication bias (Fig. 2). A further limitation is that no data is reported on whether patients with recurrence reported new, recurring or changing symptoms, when they developed a recurrence. It is well acknowledged that there is a wide range of inter- and intra-observer variability when diagnosing dysplasia on the basis of a histopathological specimen. A further limitation of this study, therefore, is that this data has been collated based upon the histopathological opinion of numerous histopathologists in many depart ments in several countries over a long period of time. Therefore, there is bound to be variation in the interpre tation of histological grade. However, we feel that this review provides a pragmatic reflection of the real life situation, where management is carried out on an inten tion-to-treat basis, and where inter- and intra-rater vari ability is commonplace. These findings confirm and quantify the malignant poten tial of dysplastic laryngeal lesions. The risk of transforma tion is dependent particularly on the severity of grade of disease. This should be taken into account when deciding on the management of these lesions. It would also appear that surgical resection may result in less transformation, however, further research is required to confirm this. Finally, transformation can occur late and does not appear to be dependent on histological grade. Further more, it is not clear whether, on recurrence, patients Clinical implications
exhibited any new symptoms. There is little evidence therefore, to support the early discharge of patients with mild ⁄ moderate dysplasia, which is practised by some clinicians.
Research recommendations
To ensure that data from future studies will be more robust, standardisation of grading systems, interventions and follow-up protocols would be beneficial. Prospective studies examining different treatment and follow-up strat egies are needed. In addition, the natural history of recur rence should be studied. If patients develop further symptoms on recurrence, then early discharge, especially for patients with mild and moderate dysplasias, may be a pragmatic solution. Laryngeal dysplasia carries a significant risk of malignant transformation, even after initial surgical treatment. The risk of malignant transformation is greater with higher grades of dysplasia. Due to the potential for late malig nant transformation, there is no evidence to support early discharge. There was no strong evidence that surgical excision may be more effective than other treatment modalities in preventing recurrence. Further research on this is recommended. Conclusions Keypoints • Wide variability in malignant transformation rates and management/follow-up strategies for laryngeal dysplasia are reported in the literature. • This systematic review found an overall malignant transformation rate of 14%. • The malignant transformation rate increases with severity of dysplasia grade (10.6% for mild ⁄ mode rate, 30.4% for severe ⁄ carcinoma in situ ). • Treatment modality did not show a significant effect on this transformation rate, however the data was limited. • The mean time to transformation was 5.8 years. • There is little evidence to support the early discharge of patients with mild ⁄ moderate dysplasia practised by some clinicians. Competing interests None declared.
2010 Blackwell Publishing Ltd • Clinical Otolaryngology 35, 364–372
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