Hayes Martin lecture. Vicissitudes of head and neck cancer

In this study 136 of 167 patients (81 percent) with squamous cell carcinoma of the anterior tongue had no clinically evident neck node metastases. In 92 patients who received no elective treatment to the neck, 8 percent had recurrences at the primary site and 25 percent had recurrences in the neck with the primary site controlled. Three factors identify those patients at highest risk for harboring occult metastases: clinical size of the primary tumor, the presence of perineural invasion, and the sex of the patient (men fare worse). Patients with primary tumors of 1 cm or less in greatest diameter should not have elective treatment to the at-risk neck, patients with tumors greater than 3 cm in greatest diameter should receive treatment to the at-risk neck, and patients with cancer demonstrating perineural invasion should receive treatment to the at-risk neck. In the future, randomized controlled trials evaluating the efficacy of elective treatment to the at-risk neck should include only those patients at intermediate risk for harboring occult neck node metastases (that is, primary tumors 1 to 3 cm in greatest dimension without perineural invasion). Careful retrospective multifactorial analysis of the natural history and prognosis should always precede prospective, randomized trials to prevent the randomization of patients whose outcome can be predetermined on the basis of clinical and histologic characteristics.