Challenging the 20% Rule: Is a Fixed Cutoff Still Appropriate for Elective Neck Dissection in cN0 Necks?

BACKGROUND: The 20% occult metastasis threshold proposed by Weiss in 1990 has long guided elective neck dissection (END) in clinically node-negative (cN0) head and neck cancer, despite advances in surgical safety and oncologic evidence. METHODS: An international web-based cross-sectional survey evaluated acceptable risk thresholds and attitudes toward END among head and neck (HN) surgeons, other healthcare professionals, and non-healthcare participants. The primary outcome was the acceptable occult metastasis risk to justify END; secondary outcomes included acceptable 5-year mortality increase and complication trade-offs. RESULTS: Of 2077 responses, 2008 were analyzed. Overall, 55% would undergo END at ≤ 10% occult metastasis risk and 86% at 20%. Responses differed significantly across groups (p < 0.0001), with lower thresholds among HN surgeons; 57% endorsed END at ≤ 10% and 92% at ≤ 20%. Among HN surgeons, a threshold of 5% or lower was considered sufficient to include the following levels in the dissection: 78% of surgeons for Level IIB, 75% for Level IV, and 69% for Level V. The majority of HN surgeons (90%) considered it more appropriate to calculate the individual risk and discuss the indication with the patient rather than relying on a fixed threshold. CONCLUSIONS: Most respondents-particularly HN surgeons-favor lower thresholds than the historical 20%, supporting individualized risk-based decision-making rather than reliance on a fixed cut-off.

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Journal
Head & Neck
Published
2026-08-26
DOI
https://doi.org/10.1002/hed.70444
Primary Topic
Head and Neck Cancer Studies
Type
article
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article

Challenging the 20% Rule: Is a Fixed Cutoff Still Appropriate for Elective Neck Dissection in cN0 Necks?

Katarzyna Fułek, Shalva R Gvetadze, Luca Giovanni Locatello, Domenico Amadio et al.
Head & Neck
Head and Neck Cancer Studies
article

Challenging the 20% Rule: Is a Fixed Cutoff Still Appropriate for Elective Neck Dissection in cN0 Necks?

Katarzyna Fułek, Shalva R Gvetadze, Luca Giovanni Locatello, Domenico Amadio, Matteo Di Bari, Çağrı Becerik, Aina Brunet, Andrea Galli, Hazan Başak, Elisa Laura, Ignacio Javier Fernandez, Magda Barańska, Leison Maharjan, Amaya Roldán Fidalgo, Vittorio Rampinelli, Federico Giuseppe Quarta, Pasquale D’Alessio, Sarah Atallah, Dorota Świątek, Samuel Oluyomi Ayodele, Luca Gazzini, Laith Dahoun, Daniele Borsetto, Virginia Dallari, Francesca Zanghi, P. Pérez-Chacón, Ana Penezić, Diana Ugorová, Carola Gillone, Olga Komiażyk, Eleonora Trecca, Kylian Ladrière, Giulia Gobbo, Nikola Đorđević, Y‐CEORL GROUP, Luca Calabrese, Ismail S. Nouh, Marco Zaraca
article en

Abstract

BACKGROUND: The 20% occult metastasis threshold proposed by Weiss in 1990 has long guided elective neck dissection (END) in clinically node-negative (cN0) head and neck cancer, despite advances in surgical safety and oncologic evidence. METHODS: An international web-based cross-sectional survey evaluated acceptable risk thresholds and attitudes toward END among head and neck (HN) surgeons, other healthcare professionals, and non-healthcare participants. The primary outcome was the acceptable occult metastasis risk to justify END; secondary outcomes included acceptable 5-year mortality increase and complication trade-offs. RESULTS: Of 2077 responses, 2008 were analyzed. Overall, 55% would undergo END at ≤ 10% occult metastasis risk and 86% at 20%. Responses differed significantly across groups (p < 0.0001), with lower thresholds among HN surgeons; 57% endorsed END at ≤ 10% and 92% at ≤ 20%. Among HN surgeons, a threshold of 5% or lower was considered sufficient to include the following levels in the dissection: 78% of surgeons for Level IIB, 75% for Level IV, and 69% for Level V. The majority of HN surgeons (90%) considered it more appropriate to calculate the individual risk and discuss the indication with the patient rather than relying on a fixed threshold. CONCLUSIONS: Most respondents-particularly HN surgeons-favor lower thresholds than the historical 20%, supporting individualized risk-based decision-making rather than reliance on a fixed cut-off.

Head & Neck
University of Foggia (IT), University of Verona (IT), University of Udine (IT), Cliniques Universitaires Saint-Luc (BE), Patan Academy of Health Sciences (NP), Ankara University (TR), University of Nis (RS), Vita-Salute San Raffaele University (IT), Central European University (AT), King Hussein Medical Center (JO), Cambridge University Hospitals NHS Foundation Trust (GB), Bandırma Onyedi Eylül University (TR), Wroclaw Medical University (PL), Sorbonne Université (FR), Institut d'Investigació Biomédica de Bellvitge (ES), Hospital Son Llatzer (ES), Ospedale Santa Chiara (IT), Ospedale di Bolzano (IT), Ospedale "Santa Maria delle Croci" di Ravenna (IT), University Hospital Bratislava (SK), Mercy University Hospital (IE), Surgical Specialties (Canada) (CA), Ospedale Civile Di Ivrea (IT), Catholic University of Croatia (HR), Azienda Ospedaliera Santa Maria Degli Angeli (IT), CTO Andrea Alesini (IT), Medical University of Lodz (PL), Central Clinical Hospital (PL), P.A. Hertzen Moscow Oncology Research Institute (RU), Łukasiewicz Research Network – PORT Polish Center for Technology Development (PL), Azienda Ospedaliera di Desio e Vimercate (IT), Istituti di Ricovero e Cura a Carattere Scientifico (IT), Obafemi Awolowo University Teaching Hospitals Complex (NG), Hospital Universitario Río Hortega (ES), Azienda Ospedaliera Ospedale Civile di Legnano (IT), Ospedale Civile di Vittorio Veneto (IT), Hôpital Tenon (FR), Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele (IT), Obafemi Awolowo University (NG), Comenius University Bratislava (SK), University of Brescia (IT), Alexandria University (EG), University of Bologna (IT)
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Openalex Percentile: Top 8%
Head and Neck Cancer Studies
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