• N3 Neck;
  • quamous cell carcinoma;
  • chemoradiation;
  • surgical resection;
  • Level of Evidence: 2c.



Although treatment paradigms have shifted to recommend primary chemoradiation therapy (CRT) for advanced head and neck squamous cell carcinoma, few studies include any significant number of patients with N3 (>6 cm) neck disease. The objective of this study was to determine if primary chemoradiation therapy has equivalent overall survival (OS) and disease-free survival (DFS) when compared to primary surgical resection in patients with N3 neck disease.

Study Design:

Nonrandomized, single-institution, retrospective cohort study.


Retrospective analysis of 100 patients treated for HNSCC with N3 neck disease between 1989 and 2009 was performed.


Patients who received primary surgery had better OS and DFS than those who had primary chemoradiation (P = .047), with a 5-year OS of 68% (95% confidence interval [CI], 45%-84%) versus 32% (95% CI, 19%-45%), and a 5-year DFS of 64% (95% CI, 41%-80%) versus 32% (95% CI, 19%-45%). Neck dissection following primary treatment with CRT did not improve OS. For patients with nonoropharyngeal squamous cell carcinoma with N3 neck disease, those who underwent primary surgery (n = 14) had significantly better OS than those who had primary CRT (n = 32, P = .02). Patients with oropharyngeal disease had better outcomes than other sites regardless of treatment modality, with 5-year OS of 54% (95% CI, 38%-68%) versus 32% (95% CI, 17%-47%, P = .02), but there was no statistical difference between patients treated with primary surgery versus CRT.


Patients with head and neck squamous cell cancer and N3 neck disease have at least equivalent survival with primary surgical treatment versus primary CRT. Primary surgical resection with appropriate adjuvant therapy should be considered for patients with resectable N3 disease, especially patients with nonoropharyngeal sites. Post-CRT neck dissections did not change the OS of patients with N3 disease. Laryngoscope, 2011