Between 1970 and 1980, we treated 107 previously untreated patients with biopsy-proven carcinoma of the nasopharynx by megavoltage external radiation therapy to the primary site, the base of the skull, and both sides of the neck. Eighty-seven percent of the patients had stage IV disease (American Joint Committee, 1980). Eighteen patients developed distant metastases as the first site of relapse. Metastases appeared within 6 months after treatment in 50% of these 18 patients, and in 94% within 2 years. Median survival after the development of distant metastases was 6 months. The most sensitive predictor of which patients would develop distant metastases was the size of cervical lymph node metastases at initial presentation (P = 0.003); patients without palpable cervical nodes or with cervical nodes smaller than 3 cm were the least likely to develop distant metastases (10%), followed by those patients who had cervical nodes measuring 3 to 6 cm (25%), followed by those who had cervical nodes larger than 6 cm, (almost 50%). The incidence of distant metastases was not significantly influenced by age, sex, birthplace, histology, or T-stage. Studies aimed at decreasing the morbidity and mortality from distant metastases in carcinoma of the nasopharynx should be undertaken in patients who present with bulky cervical metastases.