Patterns of Spread

First Echelon Nodes


The first-echelon LN for carcinomas of face and scalp are superficial LN that form a ring around the top of the neck

  • submental
  • submandibular
  • parotid
  • postauricular (mastoid)
  • occipital
  • facial

By Pathology

Skins Cancers Local Relapse Regional Relapse Distant
Basal Cell Carcinoma Incidence of metastasis < 0.01%
Squamous Cell Carcinoma % 10% 2% at presentation
Merkel Cell % 20% at presentation

Lymphatic vessels (Pansky 3rd ed p.20)


  • frontal → ant. auricular and parotid
  • temporal and parietal → retoauricular and parotid
  • occipital → occipital and deep cervical

External Ear

  • pre- and retroauricular nodes
  • superficial and deep cervical nodes

Lymphatics of Face

  • eyelids and conjunctiva → submandibular and parotid
  • cheek → parotid and submandibular
  • Side of nose, upper lip and lateral lower lip → submandibular
  • medial lower lip → submandibular
  • Temporal and infratemporal fossa → deep facial and deep cervical nodes

By Nodal Stations

Submental Lymph Node drains from

  • medial portion of the lip (may also spread bilaterally)
  • chin

Submandibular Lymph Node drains from

  • eyelids (medial?)
  • nose, sides of
  • cheek/ buccal nodes
  • upper lip
  • lateral portion of the lower lip including commissure
  • gums
  • anterior part of the margin of the tongue

Parotid Lymph Node drains from[2]

  • frontoparietal forehead (28% of the nodal recurrence in H&N skin)
  • around the ear (20% of the nodal recurrence in H&N skin)
  • cheek (12% of the nodal recurrence in H&N skin).
  • eyelids (must be lateral eyelids) (Moore Anatomy p 668)

By Primary Tumor Site


  • 10% present with LN involvement
  • 10-15% subsequently fail in regional nodes (usually submandibular) unless treated electively.


  • Lower Lip Lymphatic Spread (5-10% risk)
  • Upper Lip Lymphatic Spread (5-10% risk)
  • Midline lesions may spread to either side
  • Commissure lesions have 19% risk of LN spread due to associated mucosal involvement

By Pathological Factors

Low Risk

T1: ≤ 1.5 cm 0-4%
well differentiated low

High Risk

T2/T3 20%
thickness > 4-6 mm 18-74%
recurrent tumors 25-45%
poorly differentiated controversial
perineural invasion 35%


  • Parotid gland is the most common basin for metastatic SCCA of H&N [1]
  • 61% of metastatic lymph nodes were located in the parotid with or without cervical lymph node involvement.
1. O’Brien CJ. The parotid gland as a metastatic basin for cutaneous cancer. Arch Otolaryngol Head Neck Surg. 2005; 131:551-555.
2. Veness MJ, Palme CE, Morgan GJ. High-risk cutaneous squamous cell carcinoma of the head and neck: results from 266 treated patients with metastatic lymph node disease. Cancer. 2006 Jun 1;106(11):2389-96. PMID: 16649220
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