Influence of previous treatment of oral squamous cell carcinoma on the geographic distribution of recurrent neck metastases: A case series of unusual level 4 metastases

Background Cervical node management is vital for the successful treatment of oral squamous cell carcinoma (OSCC). Lymphatic spread from intra-oral malignancies usually follows a predictable path. We report on two patients with isolated level 4 recurrence following previous treatment for OSCC. Methods Single institutional case series. Results Two patients, initially N0, treated by surgery and ipsilateral neck dissection, presented with recurrent OSCC. One patient received adjuvant radiotherapy. Both patients developed recurrent/new disease at 7 years and and 22 months, respectively, and had salvage surgery, one had adjuvant radiation therapy. Both, subsequently, presented again at 3 and 12 months with isolated, ipsilateral level 4 metastases. Conclusion These two patients presented with delayed skip metastases which defies normal drainage patterns. The experience with these patients and a review of the literature raises the question of addressing the treatment of level 4 lymph nodes in recurrent OSCC due to altered drainage.