{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T13:22:00Z","timestamp":1787750520532,"version":"build-2784847793"},"reference-count":20,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Head &amp; Neck"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The 20% occult metastasis threshold proposed by Weiss in 1990 has long guided elective neck dissection (END) in clinically node\u2010negative (cN0) head and neck cancer, despite advances in surgical safety and oncologic evidence.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>An international web\u2010based cross\u2010sectional survey evaluated acceptable risk thresholds and attitudes toward END among head and neck (HN) surgeons, other healthcare professionals, and non\u2010healthcare participants. The primary outcome was the acceptable occult metastasis risk to justify END; secondary outcomes included acceptable\u00a05\u2010year mortality increase and complication trade\u2010offs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Of 2077 responses, 2008 were analyzed. Overall, 55% would undergo END at \u2264\u200910% occult metastasis risk and 86% at 20%. Responses differed significantly across groups (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001), with lower thresholds among HN surgeons; 57% endorsed END at \u2264\u200910% and 92% at \u2264\u200920%. 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.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Most respondents\u2014particularly HN surgeons\u2014favor lower thresholds than the historical 20%, supporting individualized risk\u2010based decision\u2010making rather than reliance on a fixed cut\u2010off.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/hed.70444","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T12:49:08Z","timestamp":1787748548000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Challenging the 20% Rule: Is a Fixed Cutoff Still Appropriate for Elective Neck Dissection in\n                    <scp>cN0<\/scp>\n                    Necks?"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5077-9847","authenticated-orcid":false,"given":"Luca","family":"Gazzini","sequence":"first","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery, Hospital of Bolzano (SABES\u2010ASDAA) Teaching Hospital of the Paracelsus Medical Private University (PMU)  Bolzano Italy"},{"name":"Young Confederation of European ORL\u2010HNS, Y\u2010CEORL\u2010HNS  Vienna Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0901-6266","authenticated-orcid":false,"given":"Vittorio","family":"Rampinelli","sequence":"additional","affiliation":[{"name":"Young Confederation of European ORL\u2010HNS, Y\u2010CEORL\u2010HNS  Vienna Austria"},{"name":"Unit of Otolaryngology\u2010Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University of Brescia  Brescia 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Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5242-7653","authenticated-orcid":false,"given":"Leison","family":"Maharjan","sequence":"additional","affiliation":[{"name":"Young Confederation of European ORL\u2010HNS, Y\u2010CEORL\u2010HNS  Vienna Austria"},{"name":"Department of Otolaryngology and Head &amp; Neck Surgery Patan Academy of Health Sciences  Lalitpur Nepal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-5629-2954","authenticated-orcid":false,"given":"Marco","family":"Zaraca","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology\u2010Head and Neck Surgery, Hospital of Bolzano (SABES\u2010ASDAA) Teaching Hospital of the Paracelsus Medical Private University (PMU)  Bolzano Italy"},{"name":"Young Confederation of European ORL\u2010HNS, Y\u2010CEORL\u2010HNS  Vienna Austria"},{"name":"Otolaryngology\u2014Head and Neck Surgery Department University 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