Minimizing adjuvant treatment after transoral robotic surgery through surgical margin revision and exclusion of radiographic extracapsular extension: A Prospective observational cohort study

Transoral robotic surgery for oropharyngeal cancer: a systematic review on the role of margin status

INTRODUCTION

Nowadays, robotic surgery finds application in the field of head and neck in the treatment of oropharyngeal tumors. The aim of this work is to examine the efficacy of transoral robotic surgery (TORS) in performing safe oncological resections of oropharyngeal squamous cell carcinoma (OPSCC), with particular attention to the status of margins.

EVIDENCE ACQUISITION

Literature search of English-language studies focused on TORS through PubMed, the Cochrane Library and EMBASE databases. A total of 431 papers returned to search, but only 24 met the inclusion criteria. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

Within the selected studies, the overall rate of OPSCC positive margins following TORS is minimal, especially when patient selection is adequate and when TORS is used by high volume centers.

CONCLUSIONS

TORS is a very precise and viable therapeutic tool that provides good results in terms of surgical radicality with low positive margin rates and good results in terms of overall survival and disease-free survival; however, there is still a great heterogeneity in margins definition within the available literature. Consequently, even if this surgical approach is very promising, it is still challenging to draw firm conclusions nowadays.

Transoral robotic surgery without adjuvant therapy: A systematic review and meta-analysis of the association between surgical margins and local recurrence

BACKGROUND

Transoral robotic surgery (TORS) is increasingly employed in the management of oropharyngeal cancer without adjuvant treatment. Attaining safe surgical margins is paramount to preventing local recurrence (LR), but the necessary surgical margin dimension remains contentious.

METHODS

Systematic review and meta-analysis of studies reporting margin status and LR following TORS without adjuvant therapy for primary OPSCC.

RESULTS

The search identified 269 articles and 11 were selected for inclusion, with 406 patients included in the meta-analysis. Heterogeneity was noted in the definition of "close" margins. Random-effects pooled rate of positive margins was 7 % (95 % CI 0.04-0.12, I2 = 54 %, p = 0.02) and close margins was 7 % (95 % CI 0.02-0.27, I2 = 86 %, p=<0.01). The random-effects overall rate of LR was 6 % (95 % CI 0.04-0.10, I2 = 11 %, p = 0.35), 13 % (95 % CI 0.02-0.620, I2 = 0 %, p = 1.0) after a positive margin, and 3 % (95 % CI 0.03-0.24, I2 = 23 %, p = 0.26) after a close margin. Odds ratio (OR) for LR indicated higher risk of LR for positive compared to close margins (7.5; 95 % CI 1.31-42.91, I2 = 0 %, p = 0.51), and a slightly lower risk of LR between close and negative margins (2.22; 95 % CI 0.67-7.38, I2 = 0 %, p = 0.8). A lack of frozen-section analysis (OR 2.91, p = 0.36) and HPV-negative disease (OR 1.68, p = 0.03) were associated with an elevated risk of LR.

CONCLUSIONS

TORS as a standalone treatment is associated with low rates of LR; however, the literature is hampered by considerable heterogeneity in margin definitions. Larger multicentre studies are required to determine the precise margin cut-off required for oropharyngeal tumours managed with TORS alone.

Clinical Characteristics and Treatment Outcomes of Oral Cancers Using Transoral Robotic Surgery in an Endemic Region

Oral cancer poses a major health challenge in Taiwan, consistently ranking among the highest globally in both incidence and cancer-related mortality. Transoral robotic surgery (TORS) has potential advantages over open surgery, but its long-term oncologic outcomes are not well established. In this study, we sought to elucidate the role of TORS in improving treatment outcomes among oral cancer patients. A case-control study with propensity score matching was conducted in a single teaching hospital in Taiwan. It included 72 oral cancer patients in each group to analyze and compare survival outcomes between the surgical approaches. The TORS group demonstrated a higher negative resection margin rate, a lower mortality risk and better overall survival than the open-surgery group. Multivariate Cox regression analysis confirmed TORS's association with a reduced risk of death. Kaplan-Meier survival analysis and log-rank tests indicated significantly better survival outcomes for the TORS group across all cancer stages. Moreover, the TORS group exhibited improved overall survival rates for stage III and IV patients compared to the conventional open-surgery group. In conclusion, this study suggests that TORS may offer better overall survival rates and potential advantages over conventional surgery for oral cancer treatment.

Complications following salvage transoral robotic surgery with and without reconstruction: A systematic review of the literature

BACKGROUND

Transoral robotic surgery (TORS) has been used in the salvage setting for head and neck cancers both with and without reconstruction. The complications of salvage TORS and the effect of reconstruction on complications has not been studied.

OBJECTIVE

To study the complications of salvage TORS and examine the effect of reconstruction on complication rates.

METHOD

An electronic search of the English- language literature using PubMed, Medline, and the Cochrane database was conducted and a systematic review performed in accordance with PRISMA guidelines (CRD42020181057).

RESULTS

A total of 23 studies including 533 patients have been published on salvage TORS.The average patient age was 61.2 years.Prior treatment was described for 420 patients.205 (48.8%) underwent prior definitive radiotherapy (RT).160 (38.1%) underwent definitive chemoradiotherapy (CRT).Only 55 (13.1%) had prior surgery.Overall, there were 158 complications with a pooled rate of 33.6% (95%CI: 25.4-42.3%).77 were major complications requiring surgical intervention with a pooled rate of 18.9% (95% CI: 14.8-23.3%).The number of patients undergoing reconstruction among salvage cases in the literature is 59 (9.19%), with 24 local flaps and 25 microvascular free flaps.Reconstruction was associated with lower overall hemorrhage rates but had no impact on major hemorrhage rates.

CONCLUSIONS

The pooled incidence rates of major complications, major POH and emergency tracheostomy following salvage TORS are 18.9%, 10.5%, and 4.4%.The rate of death following salvage TORS is 3.6%. Reconstruction was associated with lower overall hemorrhage rate after salvage TORS but had no impact on major postoperative hemorrhage rates.

Revision Transoral Robotic Surgery for Early Stage HPV Positive Oropharyngeal Squamous Cell Carcinoma, it's Timing and Margins: Past and Present- a Prospective Single Centre Observational Study

To review cohort of patients with HPV positive early stage oropharyngeal cancer that underwent revision trans oral robotic surgery for positive or close margin for evidence of residual disease, its impact on survival and discussion about clear margin. This is a prospective observational study. Our TORS revision rate was 20.6%. 91.7% did not need radiotherapy to primary site; mean recurrence free survival is 31 months and no mortality in this cohort due to the primary disease. There is no consensus on what is clear margin. The surgical margins are a surrogate marker for later recurrences or long-term survival and this is what guides our treatment but equally attempts should be made to preserve their function and not increase the morbidity.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

Simple Summary

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

The robotic-assisted extended "Sistrunk" approach for tumors of the upper aerodigestive tract with limited transoral access: First description of oncological and functional outcomes

We report on the first clinical experience with the robotic-assisted extended "Sistrunk" approach (RESA) for access to constrained spaces of the upper aerodigestive tract. This prospective case cohort study include six patients that underwent RESA if transoral exposure could not be achieved. Three patients received previous radiation. Patients were postoperatively followed until week 16 for perioperative complications, surgical margins, and functional outcomes. In all patients RESA allowed adequate exposure and resection with negative margins. Three patients who underwent salvage surgery experienced a minor or intermediate grade postoperative bleeding. No patient developed a pharyngocutaneous fistula. Three patients recovered their swallowing to their preoperative status and the remaining three experienced an improvement. All patients experienced complete recovery of their voice. RESA has the potential to provide a new organ preservation approach for head and neck cancer (HNC) not amenable to transoral exposure and thus warrants further prospective clinical studies.

Second primary squamous cell carcinomas treated with trans oral robotic surgery: Oncological and functional results

Background

Recovery of swallowing in patients treated with trans-oral robotic surgery (TORS) is in general considered as favorable. However, patients afflicted with a secondary primary carcinoma of the head and neck may be more vulnerable to swallowing dysfunctions after trans-oral surgery as a consequence of previous treatments.

Methods

This is a retrospective monocentric study on patients undergoing TORS for second primary squamous cell carcinoma between 2013 and 2017 (follow-up until June 2021). Swallowing performance was assessed via the functional outcome swallowing scale (FOSS). Also, overall survival (OS), disease-free survival (DS) and disease-specific survival (DSS) were evaluated.

Results

Eighteen patients (median 62 years) underwent TORS with curative intent for T1-2 oropharyngeal and supraglottic secondary primaries. The average follow-up was of 52 months. All cases were resected R0 using TORS. 84% of patients had a post-treatment FOSS score equal or better upon last follow-up compared with pre-treatment. Only one patient required a percutaneous gastrostomy long term. DSS/DFS/OS at 5 years was 94%, 60%, and 67%, respectively. The main cause of death was metachronous pulmonary neoplasia.

Conclusions

Our study demonstrates encouraging results in terms of swallowing recovery in patients undergoing TORS for selected secondary primaries of the oropharynx and supraglottic larynx. Further studies into trans-oral surgery for this condition seem therefore warranted. Level of Evidence: Case series; Level 4.

Cost-utility of two minimally-invasive surgical techniques for operable oropharyngeal cancer: transoral robotic surgery versus transoral laser microsurgery

BACKGROUND

In the past few decades, a re-evaluation of treatment paradigms of head and neck cancers with a desire to spare patients the treatment-related toxicities of open surgery, has led to the development of new minimally invasive surgical techniques to improve outcomes. Besides Transoral Laser Microsurgery (TLM), a new robotic surgical technique namely Transoral Robotic Surgery (TORS) emerged for the first time as one of the two most prominent and widely used minimally invasive surgical approaches particularly for the treatment of oropharyngeal cancer, a sub-entity of head and neck cancers. Recent population-level data suggest equivalent tumor control, but different total costs, and need for adjuvant chemoradiation. A comparative analysis of these two techniques is therefore warranted from the cost-utility (C/U) point of view.

METHODS

A cost-utility analysis for comparing TORS and TLM was performed using a decision-analytical model. The analyses adopted the perspective of a Swiss hospital. Two tertiary referral centers in Lausanne and Zurich provided data for model quantificantion.

RESULTS

In the base case analysis TLM dominates TORS. This advantage remains robust, even if the costs for TORS reduce by up to 25%. TORS begins to dominate TLM, if less than 59,7% patients require adjuvant treatment, whereby in an interval between 55 and 62% cost effectiveness of TORS is sensitive to the prescription of adjuvant chemoradiation therapy (CRT). Exceeding 29% of TLM patients requiring a revision of surgical margins renders TORS more cost-effective.

CONCLUSION

Non-robotic endoscopic surgery (TLM) is more cost-effective than robotic endoscopic surgery (TORS) for the treatment of oropharyngeal cancers. However, this advantage is sensitive to various parameters, i.e.to the number of re-operations and adjuvant treatment.

Trends in Adjuvant Therapy After Surgery for Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

We aim to 1) evaluate trends in adjuvant treatment of human papilloma virus (HPV)-related oropharyngeal cancer; 2) assess change in complications and functional outcomes over time; and 3) assess change in overall and disease-free survival (DFS) over time.

STUDY DESIGN

Retrospective analysis.

METHODS

Charts of patients who underwent transoral robotic surgery for HPV-related oropharyngeal cancer between 2011 and 2019 were reviewed. Trend analysis was used to compare rate of adjuvant treatment over time. The Kaplan-Meier method was conducted to analyze overall survival (OS) and DFS.

RESULTS

Three hundred and forty-two patients met inclusion criteria. One hundred and sixty-three (47.7%) patients underwent adjuvant radiation, and 90 (26.3%) patients underwent adjuvant chemoradiation. Rate of extranodular extension decreased significantly from 38.9% to 24.0% (P = .004). Rate of adjuvant therapy decreased significantly from 90.9% to 62.5% between 2011 and 2019 (P = .001). In patients who received adjuvant treatment, rate of adjuvant chemoradiation therapy decreased significantly from 40.0% to 20.0% (P < .0005). There was a decrease in rate of 1-year gastrostomy tube dependence in patients treated in 2015 to 2019 versus 2011 to 2014 (2.2% vs. 7.1%, P = .025). In 2011 to 2014, 2-year OS and DFS were 96% and 89%, respectively; in 2015 to 2019, 2-year OS and DFS were 96% and 94%, respectively. There was no difference in OS or DFS between the two time periods.

CONCLUSIONS

The rate of adjuvant therapy, particularly chemotherapy, has decreased over time. One-year gastrostomy tube dependence rate has decreased significantly from 2011 to 2014 to 2015 to 2019. There was no change in OS and DFS over this time period.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

MRI-Based Assessment of the Pharyngeal Constrictor Muscle as a Predictor of Surgical Margin after Transoral Robotic Surgery in HPV-Positive Tonsillar Cancer

BACKGROUND AND PURPOSE

Transoral robotic surgery is an emerging strategy for treating human papillomavirus-positive cancers, but the role of MR imaging in predicting the surgical outcome has not been established. We aimed to identify preoperative MR imaging characteristics that predispose the outcome of transoral robotic surgery toward an insecure (positive or close) surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

MATERIALS AND METHODS

Between December 2012 and May 2019, sixty-nine patients underwent transoral robotic surgery at our institution. Among these, 29 who were diagnosed with human papillomavirus-positive tonsillar squamous cell carcinoma, did not receive neoadjuvant treatment, underwent preoperative 3T MR imaging, and had postoperative pathologic reports and were included in this retrospective study. Two neuroradiologists evaluated the preoperative MR imaging scans to determine the tumor spread through the pharyngeal constrictor muscle using a 5-point scale: 1, normal constrictor; 2, bulging constrictor; 3, thinning constrictor; 4, obscured constrictor; and 5, tumor protrusion into the parapharyngeal fat. The risk of an insecure surgical margin (involved or <1 mm) according to the MR imaging scores was predicted using logistic regression with the Firth correction.

RESULTS

The interobserver agreement for the MR imaging scores was excellent (κ = 0.955, P < .001). A score of ≥4 could predict an insecure margin with 87.5% sensitivity and 92.3% specificity (area under the curve = 0.899) and was the only significant factor associated with an insecure margin in the multivariable analysis (OR, 6.59; 95% CI, 3.11-22.28; P < .001).

CONCLUSIONS

The pre-transoral robotic surgery MR imaging scoring system for the pharyngeal constrictor muscle is a promising predictor of the surgical margin in human papillomavirus-positive tonsillar squamous cell carcinoma.

A new endoscopic surgical approach to the larynx, hypopharynx, and neck lymphatics: The robotic-assisted extended "Sistrunk" approach (RESA)

BACKGROUND

We report on the feasibility of a novel robotic-assisted extended "Sistrunk" approach (RESA) to the larynx, hypopharynx, and lateral neck lymphatics.

METHODS

Studies were performed using the da Vinci Xi and SP system on three cadavers comprising of three supraglottic laryngectomies, one partial hypopharyngectomy, and four lateral level II to IV neck dissections.

RESULTS

In all resections at first a central common working space overlying the hyoid bone was created. The da Vinci Xi system was used with two vestibular and two submental ports for laryngeal/hypopharyngeal resections, and an additional port through a facelift incision for level II to IV neck dissections. The da Vinci SP system was used with only one submental port.

CONCLUSIONS

We describe herein a novel endoscopic robotic approach to the larynx, hypopharynx, and neck based on the traditional "Sistrunk" procedure. The technique should help improving exposure of the primary lesion and reduce access-related morbidity to the neck.

A systematic review on Transoral robotic surgery (TORS) for carcinoma of unknown primary origin: Has tongue base mucosectomy become indispensable?

Background

Transoral robotic surgery (TORS) is increasingly used in head and neck surgery and in carcinoma of unknown primary (CUP) origin specifically. Due to the rising incidence of human papillomavirus (HPV)‐related oropharyngeal squamous cell carcinoma (OPSCC), there is a rationale for finding ways to de‐escalate treatment strategies. This review aims to test the hypothesis that TORS is a meaningful adjunct in the diagnostic (and therapeutic) pathway in CUP in head and neck.

Methods

A structured search of the literature was performed with the search terms ‘TORS’ and ‘Carcinoma of Unknown Primary’.

Results

Two hundred and seventy four cases of CUP in which TORS was used were identified for further analysis. Workup for CUP was comparable in all series with regard to physical examination, fine and/or gross needle examination of cervical nodes, fibre optic endoscopy, imaging and robot assisted mucosectomy of the base of tongue (BOT). Identification rate of the primary tumour was 72% on average (range 17%‐ 90%), and 55%‐ 96% were HPV positive. Clear margins were achieved in 60% (range 0%‐85%) of resected occult tumours. Complication rate of TORS BOT mucosectomy was low with mainly grade I‐III sequelae according to Clavien–Dindo.

Conclusions

Transoral robotic surgery seems to be a useful and safe adjunct in the diagnostic and therapeutic pathway in case of CUP in an era of increasing incidence of HPV‐positive OPSCC.

Organ Preservation and Late Functional Outcome in Oropharyngeal Carcinoma: Rationale of EORTC 1420, the "Best of" Trial

Dysphagia represents one of the most serious adverse events after curative-intent treatments with a tremendous impact on quality of life in patients with head and neck cancers. Novel surgical and radiation therapy techniques have been developed to better preserve swallowing function, while not negatively influencing local control and/or overall survival. This review focuses on the current literature of swallowing outcomes after curative treatment strategies. Available results from recent studies relevant to this topic are presented, demonstrating the potential role of new treatment modalities for early- and intermediate-stage oropharyngeal cancers. Based on this, we present the rationale and design of the currently active EORTC 1420 "Best of" trial, and highlight the potential of this study to help prioritizing either surgery- or radiation-based treatment modalities for the treatment of oropharyngeal cancer in the future.

Functional Organ Preservation Surgery in Head and Neck Cancer: Transoral Robotic Surgery and Beyond

In recent years, interest in functional organ preservation surgery (FOPS) in the treatment of head and neck cancer has increased dramatically as clinicians seek to minimize the adverse effects of treatment while maximizing survival and quality of life. In this context, the use of transoral robotic surgery (TORS) is becoming increasingly common. TORS is a relatively new and rapidly-evolving technique, with a growing range of treatment indications. A wide range of novel, flexible surgical robots are now in development and their commercialization is expected to significantly expand the current indications for TORS. In the present review, we discuss the current and future role of this organ-preserving modality as the central element in the multimodal treatment of head and neck cancer.

Personalizing Postoperative Treatment of Head and Neck Cancers

Head and neck cancer (HNC) treatment is a complex multidisciplinary undertaking. Although overtreatment can result in functional and cosmetic defects, undertreatment can result in cancer recurrence. Surgery and chemoradiotherapy are both accepted standards for the curative intent treatment of locally advanced mucosal squamous cell carcinoma of the head and neck, but are often prioritized differently depending on the site of tumor origin (e.g., oral cavity/sinonasal vs. oropharynx/larynx), tumor burden, tumor biology, quality-life considerations, and patient preference. Regardless of modalities chosen, failure to cure remains a considerable problem in locally advanced disease. For patients treated with primary surgery, high-risk pathologic features portend higher recurrence rates, and adjuvant therapy can reduce these rates and improve outcomes. This report details which tumor- and nodal-related factors are indications for adjuvant therapy, examines the impact of tumor HPV status on adjuvant treatment paradigms, and considers which systemic therapies should be used for which patients when trimodality therapy is indicated.

Transoral robotic surgery for oropharyngeal cancer: patient selection and special considerations

The increasing incidence of oropharyngeal squamous cell carcinoma (OPSCC) emphasizes the importance of optimizing treatment for the disease. Historical protocol has utilized definitive radiation and invasive open procedures; these techniques expose the patient to significant risks and morbidity. Transoral robotic surgery (TORS) has emerged as a therapeutic modality with promise. Here, the literature regarding proper patient selection and other considerations for this procedure was reviewed. Multiple patient and tumor-related factors were found to be relevant for successful use of this treatment strategy. Outcomes regarding early and advanced-stage OPSCC were analyzed. Finally, the literature regarding use of TORS in three distinct patient populations, individuals with primary OPSCC, carcinoma of unknown primary and those with recurrent OPSCC, was examined.

Positive Margins by Oropharyngeal Subsite in Transoral Robotic Surgery for T1/T2 Squamous Cell Carcinoma

Objective To compare positive margin rates between the 2 most common subsites of oropharyngeal transoral robotic surgery (TORS), the base of tongue (BOT) and the tonsil, as well as identify preoperative imaging characteristics that predispose toward positive margins. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods We compared the final and intraoperative positive margin rate between TORS resections for tonsil and BOT oropharyngeal squamous cell carcinoma (OPSCC), as well as the effect of margins on treatment. A blinded neuroradiologist examined the preoperative imaging of BOT tumors to measure their dimensions and patterns of spread and provided a prediction of final margin results. Results Between January 2010 and May 2016, a total of 254 patients underwent TORS for OPSCC. A total of 140 patients who underwent TORS for T1/T2 OPSCC met inclusion criteria. A final positive margin is significantly more likely for BOT tumors than tonsil tumors (19.6% vs 4.5%, respectively, P = .004) and likewise for intraoperative margins of BOT and tonsil tumors (35.3% vs 12.4%, respectively; P = .002). A positive final margin is 10 times more likely to receive chemoradiation compared to a negative margin, controlling for extracapsular spread and nodal status (odds ratio, 9.6; 95% confidence interval, 1.6-59.6; P = .02). Preoperative imaging characteristics and subjective radiologic examination of BOT tumors did not correlate with final margin status. Conclusion Positive margins are significantly more likely during TORS BOT resections compared to tonsil resections. More research is needed to help surgeons predict which T1/T2 tumors will be difficult to completely extirpate.