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Reviewer's report

Title: Cutaneous squamous cell carcinoma metastatic to parotid - analysis ofprognostic factors and treatment outcome.

Version: 1 Date: 22 March 2012

Reviewer number: 1

Reviewer's report:

Hong et al. have conducted a single-institution retrospective review of patientstreated at their institution for cutaneous squamous cell carcinoma of the headand neck, metastatic to the preauricular/parotid lymphatics. Studies of a similarnature have been reported by other single institutions, as well as in

multi-institutional analyses. No prospective data exists on this subject.The questions asked of me as a reviewer are answered below:

1. Is the question posed by the authors new and well defined? This is animportant area of study in a well-defined and challenging clinical scenario, butone that has been previously reported in larger cohorts, with more detailedanalyses.

2. Are the methods appropriate and well described, and are sufficient detailsprovided to replicate the work? The methods section primarily describes themanagement policy at the institution, and not the technique by which the present

study was conducted. I would suggest moving the management policy to theintroduction or discussion sections, as it is not part of the research method.

Moreover, additional information about the research method is necessary:

-How were disease specific survival and overall survival calculated?

-How was data analyzed in the Cox regression model categorized (werevariables continuous, ordinate, nominal)?

-How as primary tumor site defined?

-Was nodal involvement defined clinically or pathologically? If clinically, by

physical exam, imaging (CT, PET, MRI)?-Was the margin from the parotidectomy only, or the neck dissection and primarytumor resection also?

-What was the criteria for extracapsular extension?

-Was perineural invasion identified clinically, or pathologically? From the primarytumor, the parotid specimen, or the neck dissection?

-The extent of neck dissection is described as radical, modified radical, selective,and extended radical, but these definitions mean differing things in different partsof the world. What anatomic levels of the neck were dissected?

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-Did the authors consider any other comorbidities as "immunocompromised"(HIV/AIDS, diabetes, etc)? Why or why not?

3. Are the data sound and well controlled? The data require some elaboration,but appear to be sound based on the methods presented.

4. Does the manuscript adhere to the relevant standards for reporting and datadeposition? Yes.

5. Are the discussion and conclusions well balanced and adequately supportedby the data? The authors conclusions are generally supported by their data. Itwould be informative to the reader if they presented a table with outcomes fromother series to clearly demonstrate the similarity of the present results with thoseof other groups.

6. Do the title and abstract accurately convey what has been found? Yes.

7. Is the writing acceptable? Yes.

Major Compulsory Revisions

Methodologic issues related to #3 above should be addressed.

Nowhere in the results is the stage (clinical or pathologic) of the patientsreported. There are several well-described staging systems for cSCC, includingthe situation of parotid area metastasis (O'Brien's is well-used, but others wouldbe fine). I would suggest the authors include (clincal and/or pathologic) stage ofthe cancer at presentation be included in their analysis.

I would also suggest including a table with the results of the Cox regressionanalysis, so the reader can clearly see what variables were analyzed, and whatwas significant.

Minor Essential Revisions

I would suggest reporting median values with ranges, instead of mean values,throughout the text and tables.

The introduction spends a lot of time talking about cutaneous SCC in general,and should focus on the current clinical situation instead.

Discretionary RevisionsA table presenting the results of other similarly designed studies would beinformative to the reader, even if available only as a supplement.

Level of interest: An article of importance in its field

Quality of written English: Acceptable

Statistical review: No, the manuscript does not need to be seen by astatistician.