This retrospective study on 832 head and neck cancer patients who died between 1961 and 1985 was carried out to determine the incidence and sites of distant metastases. All patients were staged prior to definitive treatment and were autopsied. The overall incidence of distant metastases was 47 percent. The hypopharynx had the highest incidence of distant metastases (60 percent), followed by the base of the tongue (53 percent) and the anterior tongue (50 percent). Of the 387 patients with distant metastases, 91 percent died with uncontrolled tumor either at the primary site or in the neck. The lung was the most common site of distant metastases (80 percent), followed by the mediastinal nodes (34 percent), the liver (31 percent), and bone (31 percent). Overall, 6 percent of the patients had stage I disease, 20 percent had stage II disease, 32 percent had stage III disease, and 43 percent had stage IV disease. The highest incidence of distant metastases was found in those patients with stage IV disease (193 of 350 patients, 55 percent). We believe that the initial stage of disease does appear to be related to the ultimate development of the distant metastases.