title: 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.
abstract: 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 7years and and 22months, respectively, and had salvage surgery, one had adjuvant radiation therapy. Both, subsequently, presented again at 3 and 12months with isolated, ipsilateral level 4 metastases.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Thyroid, Head & Neck Cancer Foundation, New York, NY; Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, NY. Electronic address: rmachado@thancfoundation.org.
authors.forename: Rosalie A
authors.initials: RA
authors.lastname: Machado
authors.affiliation: Thyroid, Head & Neck Cancer Foundation, New York, NY; Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, NY.
authors.forename: Sami P
authors.initials: SP
authors.lastname: Moubayed
authors.affiliation: Department of Pathology, Mount Sinai Beth Israel, New York, NY.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Hernandez-Prera
authors.affiliation: Thyroid, Head & Neck Cancer Foundation, New York, NY; Department of Otolaryngology-Head and Neck Surgery, Mount Sinai Beth Israel, New York, NY.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Urken
mesh_terms: D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000556:secondary* / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009062:Mouth Neoplasms / Q000473:pathology* / Q000628:therapy*; D037981:Neck Dissection; D009364:Neoplasm Recurrence, Local / Q000000981:diagnostic imaging* / Q000473:pathology / Q000628:therapy; D049268:Positron-Emission Tomography; D014057:Tomography, X-Ray Computed