Occult level IV metastases in clinically node- negative patients with oral tongue squamous cell carcinoma M MOTIEE-LANGROUDI 1 , A AMALI 2 , B SAEDI 1 , H EMAMI 1 , F ENSANI 2 , A LOTFI 3 , M RABBANI ANARI 1 1 Otorhinolaryngology Research Center, Otolaryngology Department, 2 Pathology Department, and 3 Otolaryngology Department, Tehran University of Medical Sciences, Iran Abstract Objective: The present study was conducted to determine the rate of level IV lymph node involvement among node- negative (N 0 ) necks in patients with squamous cell carcinoma of the tongue. Methods: The study comprised 32 patients with squamous cell carcinoma of the tongue, with tumour –node –metastasis staging of T 1–3 N 0 M 0 , who were admitted to the Otolaryngology Department at Tehran University of Medical Sciences from March 2012 to March 2014. After a complete diagnostic evaluation, wide primary tumour excision (with 1.5–2 cm margins) and extended supraomohyoid neck dissection (levels I – IV) were accomplished. Results: Occult metastasis was found in 28 per cent of the patients. Level I, II and III metastases were the most common (18.75, 18.75 and 15.62 per cent, respectively). Level IV metastasis was found in 6.25 per cent of patients. Conclusion: Supraomohyoid neck dissection appears to be an appropriate treatment for N 0 tongue squamous cell carcinoma and there is no need for level IV lymph node dissection in a N 0 patient. Key words: Metastasis; Neck Dissection; Tongue; Glossectomy; Squamous Cell Carcinoma Introduction Oral cavity cancers (including tongue lesions) are common worldwide. 1 The mean age of patients with an oral cavity cancer is 64 years and there is a male predom- inance. However, oral tongue squamous cell carcinoma (SCC) (when compared with other oral cavity SCCs) is more frequent in patients aged 35 years or younger. 2 Nodal metastasis is one of the most important prog- nostic factors in oral tongue SCC. 3 Forty per cent of patients with oral tongue SCC show cervical metastases at first presentation. Even in patients with T 1 and T 2 tumours with a clinically node-negative (N 0 ) neck, 20–30 per cent of the specimens reveal pathological involvement. 2 The treatment of an N 0 neck in early- stage oral tongue carcinoma is controversial. In a study by Byers et al., 15.8 per cent of the lateral tongue carcin- oma patients had ‘skip metastases’ to lymph nodes of level III or IV. 4 Hence, level I –IV (extended supraomo- hyoid) elective neck dissection was recommended in patients with early-stage disease. However, in another study, similar outcomes were demonstrated following selective level I, II and III (supraomohyoid) neck dissec- tion in patients with N 0 necks. 3 The existing evidence indicates controversy regard- ing the extension of occult metastasis in early tongue carcinoma. It is unclear whether there is involvement of only levels I, II and III, or whether there is also fre- quent involvement of level IV. This study was carried out to determine the incidence of occult metastases in patients with oral tongue SCC and to detect the pattern of cervical node metastases. Materials and methods In this prospective study, all patients with SCC of the oral tongue, referred to Imam Khomeini Hospital Complex from March 2012 to March 2014, were inves- tigated. Patients with a clinically and radiologically staged N 0 neck were included in the study. Neck ultra- sonography and computed tomography or magnetic resonance imaging were used for radiological examina- tions. The exclusion criteria were: the presence of any clinically or radiologically positive cervical lymph node; a history of previous radiotherapy or neck surgery; recurrent tumour; the presence of medical con- traindications for surgery; and distant metastasis. All Accepted for publication 29 December 2015 The Journal of Laryngology & Otology (2016), 130, 474–477. MAIN ARTICLE © JLO (1984) Limited, 2016 doi:10.1017/S0022215116000931