Book excerpt: ObjectivesControversy exists in the choice of management of advanced oropharyngeal squamous cancer. Our objective was to establish if primary treatment with transoral robotic surgery (TORS) leads to reduction in adjuvant radiotherapy dosage and fields and treatment deintensification from chemoradiotherapy to radiotherapy. MethodsA retrospective review of adjuvant treatment regimes in all patients with pathological stage III/IV (TNM7) OPSCC treated with TORS and neck dissection between March 2013 and April 2017, identified from our prospective dataset. Adjuvant RT dosage administered following surgery was compared to the 65Gy dose specified by institutional protocol for treatment of equivalent disease with primary chemoradiotherapy.ResultsFollowing TORS and neck dissection, 32 patients received adjuvant treatment as determined by institutional protocol. Adjuvant chemotherapy was required by 19/32 (59%); all had nodes with extranodal extension (ENE) and 5 had positive resection margins. Adjuvant radiotherapy alone was required by 13/32 (41%), of whom two had nodes with ENE. Reduced radiation to the primary tumour bed was possible in 20/32 (63%), with doses between 49Gy and 63Gy and 1/32 (3%) required no direct radiation to the tumour bed. Reduced radiation to the ipsilateral neck was offered in 20/32 (63%) with doses between 50Gy and 63Gy. Patients with N2b, N2c or N3 nodal disease would have required bilateral neck radiotherapy for treatment without surgery. Following TORS and neck dissection 18/24 such cases (75%) required unilateral neck radiotherapy only. Overall, when compared to treatment that would have been required without surgery, 26/32 (81%) saw some degree of reduction in their adjuvant treatment. ConclusionsIn patients with pathological stage III/IV (TNM7) OPSCC, TORS with neck dissection, as compared to treatment with primary chemoradiotherapy, allows reduction in radiotherapy dosage to the primary tumour bed, ipsilateral neck, and contralateral neck in most cases. In cases where there is no ENE, oncological TORS resection and neck dissection enables adjuvant treatment using radiotherapy alone.