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 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.
1
Introduction
In oral squamous cell carcinoma (OSCC), the presence of pathologically positive nodes in the neck is the single most reliable predictor of a patient’s prognosis . Therefore, staging and treating the neck is a critical component of the management of OSCC . Byers et al. posited that cervical lymph node spread usually happens in a predictable manner, starting with level 1 and sequentially through the other levels . Sometimes, however, the metastases may “skip” levels 1 and 2, the “first echelon of nodes,” and go directly to level 4 . There is a 3% incidence of occult metastases in level 4 according to the studies by Shah et al. , however, Byers et al. has shown that an OSCC patient with a pathologically N0 neck has a 10% risk of developing subsequent metastatic disease in level 4 in patients treated in the primary setting who did not receive post-operative radiotherapy . Moreover, previous treatment of the neck may modify lymphatic drainage and predispose to metastasis in level 4. We present two cases of OSCC that were pathologically node negative in levels 1 through 3, that developed isolated level 4 metastases. We elaborate on the potential modifications of lymphatic drainage after neck dissection and review the incidence and clinical relevance of “skip metastases” to level 4 in OSCC.
2
Methods
This is a single institutional case series in a tertiary referral hospital. Institutional review board was not required to report two cases at our institution. A review of the relevant clinical records for two patients with a history of OSCC who developed delayed, isolated level 4 nodal metastases is presented.
2.1
Case 1
A 58 year-old male presented in 2007 with OSCC of the left mobile tongue. The initial staging was cT1N0M0. The patient underwent a left partial glossectomy and left supraomohyoid neck dissection. Pathological staging confirmed a pT1N0M0 tumor without lymphovascular invasion (LVI) or perineural invasion (PNI), and negative margins. There were a total of 69 histologically negative lymph nodes. The patient did not undergo post-operative radiotherapy. The patient presented again in 2014 with a biopsy-confirmed second primary OSCC located in the left mobile tongue, in close proximity to the site of the prior neoplasm. It was staged as a cT2N0M0. The patient underwent a left partial glossectomy and a contralateral prophylactic supraomohyoid neck dissection. The margins were negative, and there was suspicion of LVI but no PNI. Two of the twenty-nine harvested contralateral right-sided lymph nodes were positive for metastatic cancer without extracapsular extension. The tumor was staged as pT2N2cM0. He received adjuvant radiation therapy at a dose of 60Gy to the oral tongue and 50Gy to right levels 1 to 3 and left levels 1 and 2. In September of 2015, 17 months following the completion of radiation therapy, the patient presented with a rapidly enlarging 5.2 × 3.8 × 4 cm level 4 mass in the left neck ( Fig. 1 ). There was no evidence of any of any other local, regional or distant disease. Fine needle aspiration of the lesion was positive for squamous cell carcinoma. The mass was resected, intraoperative radiation therapy (15Gy) was delivered, and the defect was covered with a pectoralis major muscle flap. Histological evaluation demonstrated a deposit of squamous cell carcinoma with cystic changes and involvement of skeletal muscle and fibroadipose tissue. Histologic review did not reveal any evidence of residual lymph node architecture. Postoperatively, he was treated with 45Gy using intensity-modulated radiation therapy (IMRT) with concomitant cetuximab and taxotere. The patient was free from disease seven months postoperatively.
2.2
Case 2
A 71 year-old female presented in October 2013 with OSCC of the left alveolus invading the mandible. The initial staging was cT4N0M0. The patient underwent a left segmental mandibulectomy and a left supraomohyoid neck dissection. Pathology showed negative margins, positive PNI, no LVI, 24 negative left cervical lymph nodes, and was staged as pT4aN0M0. The patient received 63 Gy of IMRT to the tumor bed. She did not undergo radiation to the neck.
Twenty-seven months following the completion of radiation therapy, she presented with a second primary in the left base of tongue, extending to the lateral pharyngeal wall. She underwent a left partial glossopharyngectomy and a right supraomohyoid neck dissection. Pathology showed squamous cell carcinoma with spindle cell features (4.9 cm), PNI, indeterminate LVI, and 22 negative lymph nodes. The final staging was pT3N0M0. Three months later, she presented with a 1.6 × 1.5 cm left level 4 mass that was hypermetabolic on PETCT (SUV 2.4) and no evidence of any other local, regional or systemic disease ( Fig. 2 ). She underwent a left level 4 neck dissection that showed a deposit of squamous cell carcinoma with cystic changes centered in fibroadipose tissue and associated with extensive desmoplastic reaction. No evidence of lymph node architecture was seen in relationship with the tumor deposit.
At the time of reporting, 5 months following completion of the excision of the level 4 recurrence, the patient remains disease free.
2
Methods
This is a single institutional case series in a tertiary referral hospital. Institutional review board was not required to report two cases at our institution. A review of the relevant clinical records for two patients with a history of OSCC who developed delayed, isolated level 4 nodal metastases is presented.
2.1
Case 1
A 58 year-old male presented in 2007 with OSCC of the left mobile tongue. The initial staging was cT1N0M0. The patient underwent a left partial glossectomy and left supraomohyoid neck dissection. Pathological staging confirmed a pT1N0M0 tumor without lymphovascular invasion (LVI) or perineural invasion (PNI), and negative margins. There were a total of 69 histologically negative lymph nodes. The patient did not undergo post-operative radiotherapy. The patient presented again in 2014 with a biopsy-confirmed second primary OSCC located in the left mobile tongue, in close proximity to the site of the prior neoplasm. It was staged as a cT2N0M0. The patient underwent a left partial glossectomy and a contralateral prophylactic supraomohyoid neck dissection. The margins were negative, and there was suspicion of LVI but no PNI. Two of the twenty-nine harvested contralateral right-sided lymph nodes were positive for metastatic cancer without extracapsular extension. The tumor was staged as pT2N2cM0. He received adjuvant radiation therapy at a dose of 60Gy to the oral tongue and 50Gy to right levels 1 to 3 and left levels 1 and 2. In September of 2015, 17 months following the completion of radiation therapy, the patient presented with a rapidly enlarging 5.2 × 3.8 × 4 cm level 4 mass in the left neck ( Fig. 1 ). There was no evidence of any of any other local, regional or distant disease. Fine needle aspiration of the lesion was positive for squamous cell carcinoma. The mass was resected, intraoperative radiation therapy (15Gy) was delivered, and the defect was covered with a pectoralis major muscle flap. Histological evaluation demonstrated a deposit of squamous cell carcinoma with cystic changes and involvement of skeletal muscle and fibroadipose tissue. Histologic review did not reveal any evidence of residual lymph node architecture. Postoperatively, he was treated with 45Gy using intensity-modulated radiation therapy (IMRT) with concomitant cetuximab and taxotere. The patient was free from disease seven months postoperatively.
