Management of the Clinically N0 Neck in Maxillary Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

Background: The optimal management of the clinically node-negative (cN0) neck in maxillary squamous cell carcinoma (MSCC) remains controversial due to the relatively low yet clinically relevant risk of occult cervical metastasis. While elective neck dissection (END) has been proposed to improve oncologic outcomes, others advocate observation to avoid overtreatment. This study aimed to evaluate the impact of END versus observation on overall survival (OS) in cN0 MSCC patients. Methods: A systematic literature search was conducted in PubMed, Embase, and Scopus according to the PRISMA 2020 statement. The protocol was registered in PROSPERO (CRD420261345038). Studies including patients with maxillary SCC and clinically N0 neck comparing END with observation were eligible. Fourteen studies were included in the qualitative synthesis, and five were suitable for quantitative meta-analysis. The primary endpoint was OS. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Risk of bias was assessed using ROBINS-I, and certainty of evidence was evaluated using the GRADE framework. Results: The meta-analysis demonstrated a statistically significant survival benefit associated with END. The pooled HR for OS was 0.76 (95% CI 0.67-0.86; p < 0.001), indicating a 24% relative reduction in the hazard of death compared with observation. Importantly, statistical heterogeneity was negligible (I² = 0%), although interpretation should be cautious given the limited number of included studies. Despite this, most included studies were retrospective in design. Conclusions: END appears to provide a survival advantage in selected patients with cN0 MSCC. However, the evidence is largely derived from retrospective data. High-quality prospective multicenter studies are needed to better define the role of elective neck management in this population.