Reviewer's report Title: Cutaneous squamous cell carcinoma metastatic to parotid - analysis of prognostic 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 patients treated at their institution for cutaneous squamous cell carcinoma of the head and neck, metastatic to the preauricular/parotid lymphatics. Studies of a similar nature 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 an important area of study in a well-defined and challenging clinical scenario, but one that has been previously reported in larger cohorts, with more detailed analyses. 2. Are the methods appropriate and well described, and are sufficient details provided to replicate the work? The methods section primarily describes the management policy at the institution, and not the technique by which the present study was conducted. I would suggest moving the management policy to the introduction 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 (were variables 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 primary tumor resection also? -What was the criteria for extracapsular extension? -Was perineural invasion identified clinically, or pathologically? From the primary tumor, 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 parts of the world. What anatomic levels of the neck were dissected?

-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 data deposition? Yes. 5. Are the discussion and conclusions well balanced and adequately supported by the data? The authors conclusions are generally supported by their data. It would be informative to the reader if they presented a table with outcomes from other series to clearly demonstrate the similarity of the present results with those of 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 patients reported. There are several well-described staging systems for cSCC, including the situation of parotid area metastasis (O'Brien's is well-used, but others would be fine). I would suggest the authors include (clincal and/or pathologic) stage of the cancer at presentation be included in their analysis. I would also suggest including a table with the results of the Cox regression analysis, so the reader can clearly see what variables were analyzed, and what was 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 Revisions A table presenting the results of other similarly designed studies would be informative 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 a statistician.