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The five-year overall survival rate of patients without neck lymph node recurrence is over 50% higher than those with lymph node metastasis. This study aims to investigate the prognostic impact of computed tomogram (CT)-based radiomics on the outcome of metastatic neck lymph nodes in patients with head and neck cancer (HNC) receiving definitive radiotherapy or chemoradiotherapy for organ preservation. The pretreatment 18F-FDG PET/CT of 79 HNC patients was retrospectively analyzed with radiomics extractors. The imbalanced data was processed using two techniques: over-sampling and under-sampling, after which the prediction model was established with a machine learning model using the XGBoost algorithm. The imbalanced dataset strategies slightly decreased the specificity but greatly improved the sensitivity. To have a higher chance of predicting neck cancer recurrence, however, clinical data combined with CT-based radiomics provides the best prediction effect. The original dataset performed was as follows: accuracy = 0.76 ± 0.07, sensitivity = 0.44 ± 0.22, specificity = 0.88 ± 0.06. After we used the over-sampling technique, the accuracy, sensitivity, and specificity values were 0.80 ± 0.05, 0.67 ± 0.11, and 0.84 ± 0.05, respectively. Furthermore, after using the under-sampling technique, the accuracy, sensitivity, and specificity values were 0.71 ± 0.09, 0.73 ± 0.13, and 0.70 ± 0.13, respectively. The outcome of metastatic neck lymph nodes in patients with HNC receiving radiotherapy for organ preservation can be predicted based on the results of machine learning. This way, patients can be treated alternatively. A further external validation study is required to verify our findings. [ABSTRACT FROM AUTHOR]