Dysregulated microRNA (miR) expression has emerged as a potential prognostic tool in head and neck squamous cell carcinoma (HNSCC), but the clinical value of miR-34a remains unclear. This systematic review, meta-analysis, and trial sequential analysis (TSA) evaluated the association between tumor tissue miR-34a expression and survival outcomes in HNSCC. Following a protocol registered in PROSPERO (n. CRD420251238772), PubMed/MEDLINE, Scopus, ScienceDirect, CENTRAL, Google Scholar, and grey literature sources were searched for studies reporting overall survival (OS) or disease-free survival (DFS) stratified by miR-34a expression in HNSCC or its subsites. Hazard ratios (HRs) were extracted directly or reconstructed from Kaplan–Meier (KM) curves using the Tierney method, supported by a dedicated Python application (KM2HR). Four retrospective studies, corresponding to six study/site-specific cohorts and 318 patients, met the inclusion criteria. For OS (four cohorts), the fixed-effects model yielded a pooled HR of 2.25 (95% CI 1.48–3.41) for low versus high miR-34a expression, indicating worse survival in the low-expression group. However, the random-effects model attenuated the association (HR 1.32, 95% CI 0.32–5.54), with substantial heterogeneity (I2 ≈ 77%). For DFS (two studies), the fixed-effects model suggested poorer outcomes with low miR-34a (HR 2.92, 95% CI 1.24–6.88), whereas the random-effects model reversed the direction of effect with extremely wide confidence intervals (HR 0.19, 95% CI ≈ 0.00–129.34; I2 = 91%). TSA for OS (accrued information size 225 patients; estimated power ≈66%) crossed the monitoring boundary but did not reach the a priori information size, supporting only a tentative signal. A bioinformatic exploration of the TCGA HNSCC cohort (n = 522) showed a non-significant trend towards worse OS with low miR-34a (HR 1.24, 95% CI 0.93–1.65) and was excluded from pooling. Overall, low tumor miR-34a expression appears to be associated with poorer OS, but the evidence is limited by retrospective design, small sample size, and marked heterogeneity. miR-34a is a promising biomarker for prognostic stratification in HNSCC, yet larger, prospective, site-specific studies with standardized assays, pre-defined cut-offs, and appropriate adjustment for HPV status and clinical covariates are required before clinical implementation can be recommended.
Dioguardi et al. (Fri,) studied this question.