Level II (IIA/IIB) Lymph Node Evaluation in Head and Neck Cancer: A Retrospective Cohort Study from a Non-Endemic Region

Abstract

Background: Head and neck squamous cell carcinoma (HNSCC) remains a major global health concern, with cervical lymph node metastasis being one of the most important determinants of prognosis. Level II (2A/2B) lymph nodes, in particular, play a key role in disease spread and survival outcomes. This study aimed to assess the prognostic impact of level II lymph node metastasis and evaluate the concordance between clinical and pathological staging in patients undergoing neck dissection. Methods: We retrospectively analyzed 138 non-metastatic HNSCC patients treated between 2007 and 2015. Clinical staging was standardized according to the AJCC 8th edition. Level II lymph nodes were dissected and evaluated separately by two independent pathologists. Survival outcomes were assessed using Kaplan-Meier analysis and Cox proportional hazards models. Correlation between clinical and pathological staging was examined using Pearson correlation analysis. Results: The median follow-up was 55.6 months. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 62.4% and 60.1%, respectively. There was a strong correlation between clinical and pathological staging (r = 0.871, p < 0.001). Patients with level II metastasis had significantly worse outcomes, with median OS of 27 months versus an estimated 128 months among those without involvement (p = 0.008), and median DFS of 17.3 versus 114 months (p = 0.004). Age was identified as an independent predictor of mortality in multivariate analysis. Conclusions: Metastasis to level II lymph nodes is a strong adverse prognostic factor in HNSCC. These findings highlight the importance of detailed nodal evaluation in guiding neck dissection strategy, risk stratification, and subsequent adjuvant treatment decisions.