Level IV neck dissection as an elective treatment for oral tongue carcinoma-a systematic review and meta-analysis

Oral Surg Oral Med Oral Pathol Oral Radiol. 2020 Oct;130(4):363-372. doi: 10.1016/j.oooo.2020.04.810. Epub 2020 Jun 13.


Objective: The purpose of our systematic review was to investigate the prevalence of level IV involvement and skip metastases in patients with clinically negative neck (cN0) oral tongue squamous cell carcinoma (OTSCC). The occurrence of occult metastases to lower levels in the neck (levels IV and V) or the development of an erratic distribution of cervical metastases ("skip metastases") that bypass the upper neck levels (levels I to III) and go directly to level IV or V challenges the role of supraomohyoid neck dissection in the treatment of OTSCC; therefore, controversy exists over including level IV cervical nodes during an elective neck dissection of OTSCC.

Study design: Our search included all studies published from 1989 until January 2018 in the Cochrane Library, PubMed, EMBASE, and Web of Science. Abstracts and full-text articles that were deemed potentially relevant were screened. Data from the studies were extracted by using standardized tables, and a meta-analysis was conducted.

Results: In total, 3000 abstracts and 269 full text articles were screened, and 11 studies were included in this analysis. Among the 498 patients included, 16 had level IV involvement, representing involvement of 2.8%. The incidence for skip metastasis to level IV was low as well.

Conclusions: We recommend elective neck dissection that includes levels I to III in selected patients with OTSCC and cN0 neck.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Carcinoma, Squamous Cell* / pathology
  • Humans
  • Lymph Nodes / pathology
  • Lymphatic Metastasis
  • Neck Dissection
  • Neoplasm Staging
  • Retrospective Studies
  • Tongue Neoplasms* / pathology
  • Tongue Neoplasms* / surgery