Despite the widespread adoption of transoral robotic surgery (TORS) in oropharyngeal

cancer, several aspects of surgical strategy remain highly controversial. This round table

will focus on four hot topics that continue to challenge clinical practice: (1) the role of

radiological assessment in surgical planning, with particular attention to whether styloid

process involvement should be considered a contraindication; (2) the debate over margin

adequacy and how oncological safety should be redefined in the HPV-positive era; (3)

the relationship between perioperative bleeding and reconstructive techniques; and (4) the

potential role of neoadjuvant chemotherapy in patient selection and outcomes. Each

controversy will be addressed by expert panelists through short, case-based presentations

followed by open discussion with the audience. The session aims to provide practical

insights, highlight unresolved questions, and foster a multidisciplinary exchange to

optimize surgical decision-making in oropharyngeal TORS.

Background: HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) exhibits a markedly better prognosis than HPV-negative disease, prompting interest in treatment de-escalation to reduce long-term toxicity without compromising survival. Multiple prospective trials are evaluating approaches to tailor treatment intensity based on individual risk profiles.

Methods: This review summarizes current de-escalation strategies in HPV-positive OPSCC, including reduced-dose radiation, omission or minimization of concurrent chemotherapy, and primary surgical approaches such as transoral robotic surgery (TORS). Major clinical trials, including NRG-HN002, ECOG-ACRIN 3311, PATHOS, and ORATOR, were analyzed for oncologic outcomes, toxicity profiles, and patient-reported quality of life.

Results: Several studies demonstrate that de-escalated regimens—such as 60 Gy radiation with or without chemotherapy, or TORS followed by risk-adapted adjuvant therapy—achieve comparable locoregional control and overall survival to standard treatment, with improved functional outcomes. Importantly, patient selection is critical, relying on factors such as tumor stage, nodal burden, smoking history, and pathological features. Ongoing trials are refining risk stratification tools and assessing biomarkers for therapy individualization.

Conclusions: De-escalation strategies for HPV-positive OPSCC represent a paradigm shift toward more personalized, less morbid therapy. While early-phase studies show promising results, mature data from phase III trials are needed to define safe standards of care. Careful patient selection and multidisciplinary coordination remain essential to ensure oncologic efficacy while improving long-term quality of life.