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Squamous cell carcinoma (SCC) of the tongue is a common cancer across the globe. These cancers have a high predilection for nodal metastasis and a high incidence of occult metastasis. The management of clinically negative neck nodes (N0) remains controversial. We have undertaken a prospective study to evaluate the rate of occult nodal metastasis, the characteristic of metastasis, and assess the usefulness of tumor depth as a predictor of metastasis and as a guide to treat the neck. Prospective study between January 2000 to December 2005. Patients with SCC of the anterior 2/3rd of tongue with N0 neck were included. Wide excision of the primary and subsequent modified radical neck dissection (in patients with tumor depth &gt; 4 mm) was performed. Postoperative radiotherapy was given in patients with lymph node metastasis. Patients who had no node metastasis (p N -ve) were observed. The total number of eligible patients was 180. Occult lymph node metastasis (p N +ve) was seen in 122 (62.2%) patients (p &lt; 0.001), multiple levels of node involvement in 79 (70.5%) patients and extracapsular spread (ECS) in 38 (33.6%) patients. Patients in the p N +ve group who were disease free was 63.1% as compared to 68.2% in the p N -ve group (p = 0.36). Recurrence was seen in 28 (36.8%) patients of p N +ve group and 14 (31.8%) patients of p N -ve group. Early cancer of tongue with tumor depth &gt;4 mm was associated with predominantly high grade tumors, high incidence of occult nodal metastasis, multiple levels of nodal involvement and ECS. The disease free status of patients with occult metastasis who were treated was similar to that of patients with no nodal metastasis. Elective neck dissection appears essential for early oral tongue cancer with tumor depth &gt;4 mm as there is no investigational modality which can reliably identify patients without occult metastasis.

To Operate or Not to Operate N0 Neck in Early Cancer of the Tongue? A Prospective Study