Neck management in cT1-2N0 oral squamous cell carcinoma: Act or watchful wait?

The controversy over neck management for cT1-2N0 OSCC patients has persisted for two decades. While selective neck dissection (SND) has been deemed effective, only 30% of patients actually exhibit lymph node metastasis (LNM). SND-related complications, such as shoulder dysfunction and lymphedema, significantly impact patient quality of life, suggesting that 70% of patients may not benefit from SND. Current guidelines advocate observation, sentinel lymph node biopsy (SLNB), and SND, but the appropriate scenarios for each strategy need further exploration. Risk stratification assessment can inform treatment decisions in early-stage OSCC. This review explores histological risk factors, SLNB, gene expression profiles, and biomarkers for risk stratification. Additionally, we assess the potential value of postoperative radiotherapy (PORT) and immunotherapy, particularly immune checkpoint blockade (ICB), in cT1-2N0 OSCC. Risk-stratified approaches align with personalized medicine and precision surgery trends, while PORT and ICB may offer more reliable neck management options. This comprehensive review systematically synthesizes the past selection of therapeutic strategies for cT1-2N0 OSCC patients, alongside their respective strengths and limitations. We aspire to contribute to the optimization of treatment strategies for early-stage OSCC patients, ultimately enhancing both survival outcomes and quality of life.