Dear Editors,

I read with great interest the article by Smee et al. entitled “The significance of nodal disease in head and neck mucosal squamous cell carcinoma.”Reference Smee, Williams and Vangelov¹The authors are to be commended for presenting a large, long-term, single-institution cohort that rigorously examines the prognostic implications of nodal burden, particularly N3 disease, in mucosal head and neck squamous cell carcinoma (HNSCC).

This study provides compelling evidence that N3 nodal disease represents a dominant adverse prognostic factor, independent of primary tumour T-stage. Notably, despite nearly half of the N3 cohort presenting with T1–T2 disease, these patients experienced significantly worse local control, regional control, cancer-specific survival and overall survival compared with those with N0 or N1–N2 disease. The finding that time to both local and regional failure was markedly shortened in N3 patients underscores the aggressive biological behaviour associated with bulky nodal metastasis and suggests that nodal burden may reflect tumour biology rather than merely disease extent.

An important contribution of this work is the demonstration that poor regional control in N3 disease appears closely linked to compromised local control, highlighting the interdependence of primary and nodal disease management. This observation has practical clinical relevance, as it challenges the traditional view that nodal failure is predominantly a regional issue and reinforces the need for optimised locoregional strategies in this high-risk population.

Furthermore, the authors’ findings align with emerging evidence that routine neck dissection following chemoradiotherapy may not confer additional survival benefit in N3 disease, emphasising instead the importance of effective non-surgical multimodality treatment. In the contemporary era, further stratification by biological factors such as human papillomavirus (HPV) status, treatment intensification and systemic therapy optimisation may help refine outcomes for these patients.

Overall, this study makes a valuable contribution to the literature by clearly demonstrating the prognostic dominance of N3 nodal disease in HNSCC and provides a strong rationale for continued research into tailored therapeutic approaches for this challenging subgroup.