That was a close one

Top Line: Despite results of the ORATOR trials, transrobotic oral surgery is often performed for oropharyngeal cancers, even when adjuvant radiation is all but guaranteed, with the rationale being decreased toxicity since the oropharynx will get a lower ‘adjuvant” dose. 

The Study: Waves of patients are now presenting with post-TORS path reports detailing what is historically considered a close margin (i.e., cancer present less than 5 mm from inked margin). That’s because TORS is specifically designed to minimize the amount of healthy tissue removed, and pharyngeal constrictor muscles are usually <3 mm thick in their thinnest regions superior to the tonsils. Here is a much needed review on how to handle margin status following TORS for HPV+ oropharyngeal cancer. With scant conflicting retrospective series to lean on and no consensus on what specifically constitutes close margins in this setting, the authors look to current prospective protocols of post-TORS radiation for clarity. Even here definitions range from <1 to <5 mm. Some even consider re-resections as close margins given data suggesting disease control is worse in this setting. Also included is an interesting table of varying large institutional definitions and treatment recommendations for close margins. Some go breast-style and only consider tumor on ink as an indication for adjuvant radiation while others consider margins anywhere from <1 to <5 mm as close and reason for adjuvant treatment, and it appears no one cited dose-escalates above 60 Gy for this indication.

TBL: Many people consider very small margins following TORS for HPV+ oropharyngeal cancer not to be an indication in itself for adjuvant radiation nor a reason for dose escalation when treating otherwise.