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.

The management of head and neck cancer (HNC) requires a multidisciplinary, guideline-driven approach to optimize outcomes and minimize morbidity. Unfortunately, a subset of patients is still being treated outside of established protocols, often leading to suboptimal oncologic control, functional impairments, and complex salvage scenarios. This retrospective clinical reflection highlights several emblematic cases of inadequately treated HNC patients referred to our center for secondary management.

Our analysis focuses on patients who initially underwent incomplete, inappropriate, or delayed treatment in non-specialized centers. Common issues included: lack of proper staging before treatment, non-standard surgical approaches without clear margins, omission of adjuvant therapy when indicated, or poorly planned radiotherapy. These deviations frequently resulted in early recurrence, persistent disease, or major complications involving speech, swallowing, and airway integrity.

Through selected clinical cases, we explore the practical, ethical, and therapeutic challenges involved in managing these patients. Salvage treatments – whether surgical, radiotherapeutic, or systemic – are often technically more demanding and oncologically less effective than primary treatments delivered within guidelines. In addition, prior suboptimal treatment often compromises anatomical structures and patient performance status, making optimal recovery difficult.

This clinical case-based review also raises broader questions regarding referral practices, the role of second opinions, and the need for early multidisciplinary evaluation. It aims to prompt reflection among clinicians on the consequences of deviating from evidence-based care in HNC and to encourage systemic improvements in patient pathways. We also emphasize the psychological burden these patients carry and the difficulty in restoring their trust after prior mismanagement.

Ultimately, while reconstructive and salvage interventions are necessary and sometimes life-saving, they are rarely equivalent to getting it right the first time. Prevention, through timely referral and coordinated care in high-volume, specialized centers, remains the most effective and ethical solution.