Transoral Robotic Surgery in the multidisciplinary care of patients with oropharyngeal squamous cell carcinoma: ASCO Guideline.

J Clin Oncol. 2025 Feb 11:JCO2402755. doi: 10.1200/JCO-24-02755

An expert panel lead by Chris Holsinger provides evidence-based recommendations for the use of transoral robotic surgery (TORS) in the multidisciplinary management of oropharyngeal squamous cell cancer (OPC). This is a free access paper at the Journal of Clinical Oncology (JCO).

Since robotic surgery is now widely accessible, this recommendation guide could serve as a turning point in the clinical application of TORS and, consequently, in the overall management of oropharyngeal cancer—particularly for patients with HPV+ tumors.

Summary.

What is the appropriate evaluation and workup for patients with OPC being considered for TORS?

• Patients undergoing evaluation for oropharyngeal squamous cell carcinoma (OPC) should undergo a thorough history and physical examination by a multidisciplinary team including fiberoptic laryngopharyngoscopy to inform decision-making. (Evidence quality: Moderate; Strength of recommendation: Strong)
• A tissue biopsy should be performed to confirm the diagnosis—either through fine needle aspiration or coreneedle biopsy of a clinically suspicious neck mass or biopsy of a suspected oropharyngeal primary tumor. (Evidence quality: Low; Strength of recommendation: Strong)
• High-risk HPV testing should be done routinely on biopsy of the primary site or lymph nodes. (Evidence quality: Low; Strength of recommendation: Strong)
• High-resolution cross-sectional imaging of the oropharynx and cervical lymphatics should be obtained either with contrast enhanced CT of the neck or MRI. (Evidence quality: Low; Strength of recommendation: Strong)
• Evaluation of the chest with either a chest CT or PET-CT should be the next diagnostic step. (Evidence quality: Moderate; Strength of recommendation: Strong)
• Patients should have pretreatment speech and swallowing consultation, and evaluation of patient-reported outcomes and objective measurements using either modified barium swallow study or video-fluoroscopic swallowing study or fiberoptic endoscopic evaluation of swallowing. (Evidence quality: Low; Strength of recommendation: Strong)

What is the role of TORS in patients with HPV-positive OPC?

• TORS should be a part of the comprehensive surgical treatment, including an appropriate neck dissection. (Evidence quality: Moderate; Strength of recommendation: Strong)
• Primary surgical therapy may be used to provide a pathologically risk-adapted means to determine adjuvant therapy (Evidence quality: Moderate; Strength of recommendation: Strong)

Which patients with HPV positive OPC may be considered for TORS?

• TORS should be discussed as a treatment option for patients with T1-T2 (or selected T3 tumors that are exophytic and resection will not lead to significant functional deficit) OPC when, based on preoperative multimodal assessment, there is a high probability of achieving an R0 resection (uninvolved surgical margins). (Evidence quality: Moderate; Strength of recommendation: Strong)
• Patients with lateralized OPC are optimal candidates for TORS. (Evidence quality: Moderate; Strength of recommendation: Strong)
• Surgeons should evaluate patients for adequate transoral exposure. Any characteristics that limit exposure, such as a narrow mandibular arch, trismus, large mandibular tori, and/or neck range of motion limitations should be considered as potential contraindications to TORS. (Evidence quality: Low; Strength of recommendation: Strong)
• TORS is not recommended for tumors requiring a significant resection of the soft palate that might result in a functional deficit. (Evidence quality: Low; Strength of recommendation: Strong)
• TORS is not recommended when there is clear radiologic and/or clinical exam evidence of extranodal extension or matted nodes (Primary surgery should notbe offered in cases that have strong pretreatment indications for both postoperative radiation and chemotherapy). (Evidence quality: Low; Strength of recommendation: Strong)
• TORS is not recommended when pretreatment imaging shows involvement of the adjacent parapharyngeal fat. (Evidence quality: Low; Strength of recommendation: Strong)
• TORS is not recommended for the tumor that abuts the hyoid bone or extends into the extrinsic tongue musculature. (Evidence quality: Low; Strength of recommendation: Strong)
• TORS is not recommended for patients in whom anticoagulation or antiplatelet therapy cannot be withheld for an appropriate perioperative period. (Evidence quality: Moderate; Strength of recommendation: Strong)

Which patients with resected HPV-positive OPC should be considered for adjuvant therapy?

• Adjuvant radiation therapy should be offered to patients with close surgical margins (though a margin of 1-3 mm may be considered as adequate surgical margin), perineural invasion, or lymphovascular invasion. (Evidence quality: Moderate; Strength of recommendation: Strong)
• Adjuvant radiation therapy should be offered to patients who have 2-4 positive nodes and/or ≤1 mm ENE (There is uncertain evidence for the role of adjuvant radiation therapy in patients with a single positive node >3 cm, in the absence of other adverse features). (Evidence quality: Moderate; Strength of recommendation: Strong)
• Adjuvant radiation therapy with concurrent platinum-based chemotherapy should be offered to patients with final positive margins (tumor on ink) on surgical pathology. (Evidence quality: Moderate; Strength of recommendation: Strong)
• Adjuvant radiation therapy with concurrent platinum-based chemotherapy should be offered to patients with 5 or more positive nodes or >1 mm ENE on surgical pathology. (Evidence quality: Moderate; Strength of recommendation: Strong)

What is the role of TORS in HPV-negative OPC patient population?

• TORS may be offered to patients with early T stage (T1-T2) HPV-negative OPC as part of treatment with curative intent. (Evidence quality: Low; Strength of recommendation: Strong)
• Adjuvant therapy should be offered based on pathological evaluation of the surgical specimen for patients with early T stage (T1-T2) HPV-negative OPC who have undergone TORS. (Evidence quality: Moderate; Strength of recommendation: Strong)

What is the role of TORS in salvage/ recurrent setting in both HPV-positive and HPV-negative OPC?

• In select patients, TORS may be offered as a surgical option for salvage of recurrent or residual disease within a previously radiated field (residual, recurrent or a new primary) as part of treatment with curative intent. (Evidence quality: Low; Strength of recommendation: Strong)

II would like to highlight some obvious points. This is how we have been working for years, but it might not be that clear for some professionals in this field.

• The evaluation of patients with OPC necessarily includes fiberoptic laryngopharyngoscopy and functional evaluation of swallowing.
• Low evidence quality (seldom moderate) and strong strength of recommendations. That is what it is. We have to work with it.
• Transoral surgery should be discussed as a treatment option…
• Reasons for not offering TORS as a primary treatment for OPC (regardless of staging) are usually two. Poor expected functional outcomes (swallow) with surgery, or predictable need for adjuvant treatment. Any patient who will likely be TORS alone with good functional outcomes is a candidate for TORS.

J Granell. Feb 15, 2025.

Holsinger FC, Ismaila N, Adkins DR, Barber BR, Burnette G, Fakhry C, Galloway TJ, Goepfert RP, Miles BA, Paleri V, Patel AA, Roof SA, Starmer HM, Yom SS, Saba NF, Li R, Ku JA. Transoral Robotic Surgery in the Multidisciplinary Care of Patients With Oropharyngeal Squamous Cell Carcinoma: ASCO Guideline. J Clin Oncol. 2025 Feb 11:JCO2402755. doi: 10.1200/JCO-24-02755.