Level snore.

Head and neck surgeons debate the need to dissect level IV in a clinically-negative neck of a patient with an oral cavity primary. Team all-or-nothing claims dissecting IV maximizes local control while team minimalist argues the chance of finding isolated level IV disease is miniscule and outweighed by the time under anesthesia it adds. Here’s a meta-analysis of 11 retrospective and 2 prospective studies with pathologic data on >13K patients with cN0 oropharyngeal squamous cell carcinoma (SCC) receiving neck dissections of level I-IV. The overall rate of level IV disease was 2.5%, and the rate of isolated level IV disease (without concomitant disease in levels I-III) was 0.5%. Unfortunately, there wasn’t sufficient data linking details of the primary tumor with nodal location to extrapolate any correlations. TBL: This round goes to team minimalist, with routine dissection of level IV nodes for cN0 oral cavity SCC appearing extremely low-yield. | Warshavsky, JAMA Otolaryngol Head Neck Surg 2019