Risk-stratified management of the clinically node-negative neck in early-stage oral squamous cell carcinoma: Elective neck dissection versus watch-and-wait with therapeutic dissection.

OBJECTIVE: To evaluate the optimal management of the clinically node-negative (cN0) neck in early-stage (T1-T2) oral squamous cell carcinoma (OSCC) by comparing initial elective neck dissection (END) versus a Watch & Wait (W&W) approach with therapeutic neck dissection (TND) upon nodal relapse. DATA SOURCES: Studies comparing END versus W&W/TND in T1-T2 cN0 OSCC patients were searched on PubMed till January 2026. PET imaging data were also assessed for nodal staging and surveillance. REVIEW METHODS: Studies comparing END versus W&W/TND in T1-T2 cN0 OSCC patients were searched on PubMed up to January 2026. This comprehensive systematic review without meta-analysis (SWiM) qualitatively synthesized data regarding key outcomes: overall survival (OS), disease-specific survival (DFS), disease-free survival (DFS), nodal recurrence rates, and treatment-related morbidity. Effect estimates from landmark clinical trials and meta-analyses were evaluated to establish a risk-stratified framework. RESULTS: END demonstrated improved 3-year OS (80.0% vs. 67.5%; HR 0.64, P = 0.01) and DFS (69.5% vs. 45.9%; P < 0.001) compared to TND, alongside significantly lower nodal recurrence (15.1% vs. 41.5%; OR 0.25, P < 0.00001). In low-risk patients (T1 tumors, DOI <4 mm, well-differentiated histology), a strict W&W protocol incorporating operator-dependent ultrasound, fine-needle aspiration cytology (FNAC), and PET surveillance achieved comparable DSS. CONCLUSION: END provides superior survival and regional control in higher-risk T1-T2 cN0 OSCC. Conversely, a risk-stratified W&W strategy incorporating multimodal surveillance or staging via sentinel lymph node biopsy (SLNB) is highly effective for select low-risk, compliant patients, optimizing oncologic outcomes while minimizing treatment-related morbidity.