Level V Metastases in Node-Positive Oral Squamous Cell Carcinoma: Beyond Level IIA and III.

Introduction: Surgical management of level V in clinically node positive (cN+) oral squamous cell carcinomas (OSCCs) is controversial. The objectives of the study were to identify predictors of level V metastases in cN+ OSCC.

Methods: This retrospective study is based on institutional data of operated cN+ OSCC between April 2018 and December 2022. Clinical and pathological parameters were subjected to univariate analysis. Significant parameters in univariate analysis were further subjected to multivariate analysis. A p value of less than 0.05 was considered statistically significant.

Results: None of cN1 or pN1 patients had a level V metastasis. No skip metastasis to level-V was noticed. Total number of positive lymph nodes, lymph node ratio (LNR), extranodal extension, pN classification, and the presence of level II and III metastases were found to be significant predictors for level V metastases. The post hoc analysis suggested that ≥5 positive nodes, LNR >0.1, and pN3 status were independent risk factors for level V metastases.

Conclusion: Selective neck dissection for N+ OSCC is feasible in the N1 neck, preferably where nodal metastases is limited to level-I only. Patients with a bulky nodal disease, particularly those with N3 neck, ≥5 positive nodes, ENE, and metastatic lymph nodes in levels II and III should be offered comprehensive neck dissection.