Background. Tumor cell biological factors, such as urokinase plasminogen activator (uPA) and its inhibitor plasminogen activator inhibitor-1 (PAI-1), cathepsin D, and c-myc play a role in tumor invasion, metastasis, and proliferation. In this study, the prognostic importance of these factors in patients with primary head and neck squamous cell carcinoma (HNSCC) was evaluated and correlated with clinicopathologic variables.Methods. In 46 paired primary tumors and normal tissues, levels of uPA, PAI-1, cathepsin D, and c-myc amplification were determined. The clinical follow-up was over 10 years. Relationships between cell biological factors and patient and tumor characteristics were studied by the Mann-Whitney test. The Cox proportional hazard model was used for univariate and multivariate analysis.Results. In this study, only a high level of PAI-1 was associated with a significantly shorter disease-free survival (p < .01). PAI-1 levels were higher in tumors with perineural invasion (p < .01). Both PAI-1 and uPA levels were higher in patients who smoked (p < .01 and p ¼ .02). In univariate analysis, smoking (p ¼ .04), excessive alcohol intake (p ¼ .02), perineural invasion (p ¼ .001), and vaso-invasion (p ¼ .009) were associated with a shorter disease-free survival. The only factor related to overall survival was perineural invasion (p ¼ .045). The combination of a high PAI-1 level and perineural invasion appeared to be a significant predictor of a shorter disease-free interval (p ¼ .01).Conclusion. PAI-1 may present a novel prognostic factor for patients with HNSCC. Perineural invasion and PAI-1 level combined seemed to be prognostic for disease-free survival. Keywords: head and neck cancer; uPA; PAI-1; perineural; invasion Head and neck squamous cell carcinoma (HNSCC) represents the sixth most common cancer worldwide. 1 Annually there are approximately 500,000 new cases of HNSCC worldwide, 2500 cases in The Netherlands alone. 2,3 Despite advances in diagnosis and therapy, long-term survival of HNSCC patients has only moderately improved during the past 20 years. This is due to the relatively high local recurrence rate, metastatic spread, and secondary primary cancers. About 10% to 20% of the patients develop regional recurrences, 4,5 25% to 30% distant metastases, 6 and 5% to 36% develop a second primary tumor in the head and neck region. 4 Tumor status and especially cervical lymph node status are regarded as the most important prognostic factors for overall survival. It has been reported that the 5-year overall survival is reduced by approximately 50% in patients with a node Correspondence to: E. M. J. J. Berns