Risk-adapted neck dissection in salivary gland carcinoma: integrating occult nodal metastasis patterns with contemporary guidelines.

INTRODUCTION: Salivary gland carcinomas (SGCs) are rare and histologically diverse malignancies of the head and neck. They present significant challenges for standardized treatment due to varied metastatic behavior and limited high-level evidence. The extent of neck dissection remains controversial, influenced by tumor grade, histological subtype, and anatomical origin. This review evaluates current evidence and guideline recommendations to define an evidence-based, risk-adapted approach to neck dissection in SGC. METHODS: A comprehensive review of epidemiological data, retrospective cohort studies, meta-analyses, and major clinical guidelines was conducted. Particular attention was given to patterns of cervical metastasis, the impact of histological grading on management, complication rates, and diagnostic tools that guide surgical planning. RESULTS: The incidence of occult nodal metastases (ONM) varies widely by tumor type and grade, ranging from 10% to over 60% in aggressive subtypes. Low-grade tumors with intraglandular spread often warrant selective neck dissection (levels I-III), while high-grade or T3-T4 tumors benefit from more comprehensive neck dissection (levels I-V) due to increased risk of skip metastases. Preoperative imaging, Core Needle Biopsy (CNB), and intraoperative frozen sections are essential to accurately assess risk and avoid the morbidity associated with delayed or revision surgery. CONCLUSION: A one-stage, risk-adapted neck dissection strategy tailored to tumor biology and diagnostic findings improves oncological outcomes and minimizes complications. While low-risk cases may be managed with selective or limited neck dissection, high-risk SGCs require comprehensive management to achieve regional control. Standardized protocols based on robust prospective data remain an unmet need.