DISTRIBUTION OF CERVICAL LYMPH NODE
METASTASES FROM SQUAMOUS CELL
CARCINOMA OF THE UPPER RESPIRATORY
AND DIGESTIVE TRACTS
The records of 2,044 patients with previously untreated squamous cell car-
cinomas of the head and neck were reviewed in order to define the incidence
and topographical distribution of lymph node metastasis on admission. The
common regions of metastasis are presented for each of the seven individual
head and neck sites selected for study. Knowledge of the preferred areas
of spread and those that are almost never involved allows the design of more
adequate plans to manage the individual lesions.
HE PURPOSE OF THIS REPORT IS TO DEFINE
T the incidence and topographical distribu-
tion of lymph node metastasis on admission in
patients with squamous cell carcinomas of the
major anatomical sites of the upper respira-
tory and digestive tracts.
The records of 2,044 patients with pre-
viously untreated squamous cell carcinoma of
the head and neck, seen from 1948 through
1965 at The University of Texas at Houston
M. D. Anderson Hospital and Tumor Insti-
tute, were reviewed. Seven major head and
neck regions were studied: oral tongue, floor
of mouth, faucial arch, oropharynx proper, su-
praglottic larynx, hypopharynx, and nasophar-
ynx. The nodal staging system (Table 1) has
been used since the mid-1950’s. A “clinically
positive” lymph node is usually greater than 1
cm, spherical rather than a flat ovoid, and
harder than the nonmetastatic lymph node.
Presented at the Scientific Program of the Amcrican
Society of Therapeutic Radiologists, Phoenix, Ariz.,
Oct. 28-31, 1971.
From the Department of Radiotherapy, The Univer-
sity of Texas at Houston M. D. Anderson Hospital and
Tumor Institute, Houston, Tex.
Supported by Grants No. CAW294 and CA05654,
from the National Cancer Institute, National Institute;
of Health, U. S. Public Health Service.
+ Radiotherapist and Associate Professor o€ Radio-
Address for reprints: Robert Lindberg, MD, The De-
partment of Radiotherapy, The University of Texas at
Houston M. D. Anderson Hospital and Tumor Insti-
tute, Houston, Tex. 77025
Received for publication January 20, 1972.
OF NECK DISEASE
SITE AND T STAGING
The incidence of cervical node metastasis
on admission increases sharply as the size of
the primary increases in lesions o f the oral
tongue, floor of mouth, retromolar tri-
gone/anterior faucial pillar (RMT-AFP),
and soft palate (Tables 2 and 3). The fre-
quency of multiple unilateral as well as bilat-
eral and/or fixed node metastases also in-
creases with the size of the primary for the
same sites. The incidence of multiple nodal
metastases in lesions of the tonsillar fossa, base
of tongue, supraglottic larynx, and hypophar-
ynx is not strongly correlated with the staging
of the primary. This lack of correlation re-
flects the aggressiveness of the primary lesions.
In oropharyngeal wall lesions, even though
the incidence o f metastases relates well to the
increasing T stage, the multiplicity of nodes is
not as strongly related. The incidence of TIN,
lesions of the supraglottic larynx appears dis-
proportionately high (Table 4). A lesion is
classified T4 because of the local extension,
i.e., pre-epiglottic involvement. The bulk of
I ABLE 1. Nodal Staging System
clinically positive node.
N1-Single clinically positive node
clinically positive node > 3 cni in
3 cni in
cliiiically positive ipsilateral nodes.
fixed node (s) clinically positive.
positive bilateral nodes, fixed or not
CERVICAL LYMPH NODE METASTASES - Lindberg
Squamous Cell Carcinoma, 1948 through 1965
2. Per cent of Nodal Metastasis by T Stage*
3. Per cent of Nodal Metastasis by T Stage*
Squamous Cell Carcinoma, 1948 through 1965
Floor of mouth
* TI-Tumor measuring 2 cm or less in largest
Tz-Tumor measuring from 2 cm to 4 cm in largest
diameter with or without minimal infiltration
in depth or extension to adjacent structures.
T3-Tumor measuring more than 4 cm in largest
diameter. Oral tongue: up to one half of the
tongue may be irivolved; Floor o f
fixation to the periosteum or pressure defect
T4-More advanced than Ta. Oral tongue: involve-
ment of more than one half of the tongue
and/or msssive extension into the floor of
mouth, with or without involvement of the
mandible; Floor o f mouth: massive invasion
of root of tongue.
cancer may be the same in T, and T4 lesions,
which explains the apparent discrepancy. In
nasopharyngeal lesions, the percentage of pa-
tients with nodal metastasis is really the same
for all stages of the primary lesion, again re-
flecting the aggressiveness o f small primaries
Analysis of the 1,155 patients (57% of the
2,044) who presented with clinical evidence of
cervical node metastasis on admission was un-
dertaken to determine the topographical dis-
tribution of the nodal metastases. Each side of
the neck is divided into nine nodal regions
1. Submental nodes are located in the trian-
gle bounded by the anterior bellies of the di-
gastric muscles and the hyoid bone.
2. Submaxillary triangle nodes lie along the
lower border of the mandible in the submaxil-
lary triangle and are divided into three
groups-preglandular, prevascular, and retro-
3. Subdigastric nodes are located below the
level of the greater cornu o f the hyoid bone,
and include the upper jugular nodes as well
as the tonsillar node.
4. The midjugular node is usually a single
node at the bifurcation Of the common
tid just below the hyoid bone.
Rase of tongue
* Defined in: MacComb, W. S., and Fletcher, G. H.:
Cancer of the Head and Neck. Baltimore, Williams
and Wilkins, 1967; p. 185.
5. Low jugular nodes are located along the
internal jugular vein just above the anterior
belly of the omohyoid muscle.
6. Upper posterior cervical nodes lie at the
upper end o f the spinal accessory chain. The
uppermost node is beneath the sternocleitlo-
T A m e 4. Per cent of Nodal Metastasis by ?' Stage
Squamous Cell Carcinoma. 1918 throuqh 1965
7 . 5
* T Stage defined in: Fletcher, G. H., Jesse, R. H.,
Lindberg, R. D., and Koons, C. R.: The place of
radiotherapy in the management of the squamous
cell carcinomas of the supraglottic larynx. Am. J.
Of the digastric
R o ~ ~ g ~ ~ g l e O d 8 B l ~ 9 ~ a c c o m b ,
G. H.: Cancer of the Head and Neck. Baltimore,
Williams and Wilkins, 1967; P. 232.
X T Stage defined in: Chen, I ( . Y., and Fletcher.
G. H.: Malignant tumors of the nasopharynx. Radiology
99: 165-171, 1971.
w. s., and Fletcher,
CANCER June 1972
Mid Posterior Cnviul
Frc. 1. Nodal regions of the neck.
mastoid muscle at
those of the spinal accessory chain at the same
level as the midjugular nodes.
8. Low posterior cervical nodes are located
at the lower end of the spinal accessory chain.
9. Supraclavicular nodes are located just
above the clavicle in the transverse lymphatic
chain which connects the jugular and spinal
The nodal distribution and the N stage on
admission are shown for oral tongue and floor
of mouth (Fig. 2), retromolar trigone/anterior
faucial pillar, soft palate, and tonsillar fossa
(Fig. 3), base of tongue and oropharyngeal
walls (Fig. 4), and supraglottic larynx, hypo-
pharynx, and nasopharynx (Fig. 5).
An analysis of the initial lymph node distri-
bution shows the following:
1. Oral tongue: Subdigastric nodes are the
the tip of the mastoid
cervical nodes include
most commonly involved. After the nodes of
the submaxillary triangle, the midjugular
nodes are next. Submental, low jugular, and
posterior cervical nodes are seldom involved.
2. Floor of mouth: The nodes of the sub-
maxillary triangle are most commonly in-
volved because of the anterior location of the
majority of lesions. Subdigastric nodes, how-
ever, are also frequently involved. Submental
nodes are not frequently involved, in spite of
the anterior location o f the tumors. Low jugu-
lar and posterior cervical nodes are rarely in-
3. Oropharynx: Metastases from primary le-
sions of the oropharynx have some common
locales. Subdigastric nodes are most commonly
involved in all sites. The nodes of the sub-
maxillary are seldom involved, and clinically
positive submental nodes are rare.
a. RMT-AFP. The most commonly affected
node is the tonsillar node in the subdigastric
group. Because of the anterior location of the
Anterior Faucial Pillar
N. NI N t r
4 I 17 I
11 I 79 / 258=30.5%1
1179 I 38 I
FIG. 2. Nodal distribution on admission, 1948
134 I 25 1 20 I 28
NI-NI / Total
17 I 1 6 [
= 7 6 . 1
FIG. 3. Nodal distribution on admission, 1948
LYMPH NODE METASTASES -
RMT-AFP in the oropharynx, the incidence
of metastasis in the submaxillary triangle is
significant. Midjugular nodes are equally in-
volved. Posterior cervical nodes are rarely in-
b. Soft palate. Since this is a midline struc-
ture, the incidence of bilateral nodes is high.
Upper jugular nodes are most frequently in-
c. Tonsillar fossa. The tonsillar node of the
subdigastric group is almost always the first
one to be involved. The incidence of mid- and
21 I 26 I l4 I 53 I
mon, low tasis jugular
both the ipsi-
d. Base of tongue. Since the base of tongue
is midline, bilateral metastases are quite com-
mon. After the subdigastric nodes, midjugular
posterior nodes and contralaterally. is also cervical significant. nodes is Metas- com- av OropEywwl v p <
nodes are involved (bilaterally). A few pa-
tients present with posterior cervical nodes.
LOW jugular and supraclavicular nodes are
e. Oropharyngeal walls. The main spread is
along the jugular chain bilaterally since the
posterior pharyngeal wall is a midline struc-
ture. The upper jugular nodes in the subdi-
gastric group are most commonly involved,
followed by the midjugular nodes. The inci-
dence of posterior cervical node involvement
is high, whereas supraclavicular node involve-
ment is rare.
4. Supraglottic larnyx: Again, the main
spread is along the jugular chain, and upper
jugular nodes are most commonly affected, fol-
lowed closely by midjugular nodes. Bilateral
metastases are high from this midline struc-
ture. Posterior cervical nodes are seldom in-
volved. Nodes of the submaxillary triangle
and submental areas are almost never in-
5. Hypopharynx: A large majority of metas-
tases are to the jugular chain-upper,
and lower, in decreasing frequency. Since most
of these lesions arise in the pyriform sinus, the
frequency o f bilateral metastases is low. Ipsi-
lateral posterior cervical nodes are occasion-
ally involved. Submental and submaxillary
triangle nodes are very rarely involved.
6. Nasopharynx: The most commonly in-
volved ipsilateral and contralateral nodes are
the upper jugular. Nasopharynx lesions have
the highest incidence of bilateral metastases
and posterior cervical chain involvement. The
incidence of supraclavicular metastasis is sig-
nificant. Submental and submaxillary nodes
are rarely involved.
I 25 I
149 = 59%1
FIG. 4. Nodal distribution on admission, 1948
No N1 N2a Nie NlA Nle NI-N, / Total
lS1 1 27 I
N1 Nza N*B Nia N ~ B NI-NI / Total
N t r NO
[I20 I 49 I 15 I 29 I
1 1 I 43 I 147 /267 = 55.1
Nts NI-NI / Total
5 1 I 27 I 45 I 51 I
N ~ A Nts
NI-NI / Total
202 / 267 = 75.1
FIG. 5. Nodal distribution on admission, 1948