Transoral Robotic Surgery Research Articles

Adoption of otolaryngologist-head neck surgeons toward transoral robotic surgery: An international survey.

To investigate perception, adoption and awareness of otolaryngologist-head neck surgeons (OTO-HNS) toward transoral robotic surgery (TORS). An online survey was sent to 1383 OTO-HNS on the perception, adoption and awareness about TORS to members of many otolaryngological societies. The following aspects were assessed: TORS access; training; awareness/perception; indications and advantages/barriers to TORS practice. The responses were presented for the entire cohort and regarding the TORS experience of OTO-HNS. A total of 359 completed the survey (26%); including 115 TORS surgeons. TORS-surgeons carry out a mean number of 34.4 annual TORS procedures. The primary barriers to TORS were the cost of the robot (74%) and disposable accessories (69%), and the lack of training opportunity (38%). The 3D view of the surgical field (66%), the postoperative quality of life outcomes (63%) and the shorter hospital stay (56%) were the most important benefits of TORS. TORS-surgeons believed more frequently that TORS is indicated for cT1-T2 oropharyngeal and supraglottic cancers than non-TORS surgeons (p < .005). Participants believed that the priorities for the future consisted of the reduction of the robot arm size and the incorporation of flexible instruments (28%); the integration of laser (25%) or GPS tracking based on imaging (18%), all of them to improve accesses to hypopharynx (24%), supraglottic larynx (23%) and vocal folds (22%). The perception, adoption and knowledges toward TORS depend on the access to robot. The findings of this survey may help guide decisions on how improve the dissemination of TORS interest and awareness.

Ninety-day mortality following transoral robotic surgery or radiation at Commission on Cancer-accredited facilities.

Postoperative mortality for oropharynx squamous cell carcinoma (OPSCC) with transoral robotic surgery (TORS) varies from 0.2% to 6.5% on trials; the real-world rate is unknown. NCDB study from 2010 to 2017 for patients with cT1-2N0-2M0 OPSCC with Charleson-Deyo score 0-1. Ninety-day mortality assessed from start and end of treatment at Commission on Cancer-accredited facilities. 3639 patients were treated with TORS and 1937 with radiotherapy. TORS cohort had more women and higher income, was younger, more often treated at academic centers, and more likely to have private insurance (all p < 0.05). Ninety-day mortality was 1.3% with TORS and 0.7% or 1.4% from start or end of radiotherapy, respectively. From end of therapy, there was no significant difference on MVA between treatment modality. There is minimal difference between 90-day mortality in patients treated with TORS or radiotherapy for early-stage OPSCC. While overall rates are low, for patients with expectation of cure, work is needed to identify optimal treatment.

Development of machine learning models for the prediction of positive surgical margins in transoral robotic surgery (TORS).

To develop machine learning (ML) models for predicting positive margins in patients undergoing transoral robotic surgery (TORS). Data from 453 patients with laryngeal, hypopharyngeal, and oropharyngeal squamous cell carcinoma were retrospectively collected at a tertiary referral center to train (n=316) and validate (n=137) six two-class supervised ML models employing 14 variables available pre-operatively. The accuracy of the six ML models ranged between 0.67 and 0.75, while the measured AUC between 0.68 and 0.75. The ML algorithms showed high specificity (range: 0.75-0.89) and low sensitivity (range: 0.26-0.64) in detecting patients with positive margins after TORS. NPV was higher (range: 0.73-0.83) compared to PPV (range: 0.45-0.63). T classification and tumor site were the most important predictors of positive surgical margins. ML algorithms can identify patients with low risk of positive margins and therefore amenable to TORS.

Specimen-Based Resection Margins and Local Control during Transoral Robotic Surgery for Oropharyngeal HPV-Mediated Squamous Cell Carcinoma

Objectives: The aim of the study was to investigate the association of surgical margin conditions, including positive specimen margins revised to negative relative to local recurrence, disease-free survival, and overall survival (OS) within a cohort of HPV-mediated oropharyngeal squamous cell carcinoma (OPSCC) who underwent en bloc resection via transoral robotic surgery (TORS). Materials and Methods: Retrospective cohort of patients with untreated HPV-mediated OPSCC cT1 or T2 undergoing TORS resection between October 2014 and March 2020. The methodologic description of our interdisciplinary institutional approach, number of cut-through margins (CTMs) during intraoperative consultation, percentage of final positive margin cases, and disease-free survival and OS stratified by margin status and margin tumor-free distance is identified. Results: 135 patients with primary cT1/T2 HPV-mediated OPSCC met inclusion criteria. Twenty-eight of 135 (20.7%) specimens revealed CTM and were revised during the same operative setting. Three of 135 (2.2%) surgical cases had positive final margin status. Local control rate was 97%. On univariate analysis, margin distance did not impact OS. CTM and final positive margins had lower OS than initially negative margins (p = 0.044). Pathologic N-stage significantly impacted OS (p < 0.001). Conclusions: High local control rate and low final positive margin status confound the study of specimen margin-based techniques in HPV-mediated OPSCC resected en bloc with TORS. Pathologic N-stage may impact OS more than margin status. Larger numbers are needed to confirm differences.

Transoral Robotic surgery - excision of Tongue base Tumour with the Entire Hyoid bone in a Salvage Setting.

Objectives - Transoral robotic surgery (TORS) is an already well established modality of treatment for early stage oropharyngeal cancer. This case report will throw light on the role of TORS as a treatment option for oropharyngeal cancer in a salvage setting. Methods - This is a case of a 69 year old patient who was a follow up case of carcinoma base of tongue, status - post concurrent chemoradiation who presented with residual disease at the primary site. Results - TORS was used as a successful treatment modality for base of tongue carcinoma in a salvage setting. The surgical procedure included removal of the entire hyoid bone in toto along with the tumour which is not reported in literature. The procedure also helped us in achieving an R0 resection. Conclusion - TORS should be considered as an important management modality for tongue base tumours in upfront as well as salvage setting.

Postoperative opioid-prescribing practices in otolaryngology: Evidence-based guideline outcomes.

We previously reported that >50% of postoperative opioids prescribed at our institution went unused for common otolaryngologic procedures. Based on these findings, we instituted multimodal, evidence-based guidelines for postoperative pain management. In the second part of our multiphasic study, we evaluated the effects of these guidelines on (1) quantity of unused opioids, (2) patient satisfaction, and (3) institutional perceptions toward the opioid epidemic and prescribing guidelines. Standardized, procedure-specific opioid prescription guidelines were created using prospective data from the first phase of our study and evidence from current literature. Again, we examined sialendoscopy, parotidectomy, parathyroidectomy/thyroidectomy, and transoral robotic surgery (TORS). Patients were surveyed at their first postoperative appointment. Groups from Phases I and II were compared. Attending physicians were surveyed before the start of the multiphasic project and after prescribing guidelines were implemented. Prescribing guidelines led to an average reduction in prescribed morphine milligram equivalents (MME) per patient by: 48% (sialendoscopy), 63% (parotidectomy), 60% (para/thyroidectomy), and 42% (TORS). Average used MME per patient for parotidectomy was significantly reduced (64%). The proportion of unused MME per patient and patient satisfaction scores did not significantly change after guidelines were implemented. Implementation of opioid-prescribing guidelines and the use of multimodal analgesia substantially reduced the amount of opioids prescribed across all procedures without impacting patient satisfaction. 2.

Treatment Deintensification for Human Papillomavirus-Associated Oropharyngeal Cancer: Focused Review of Published Data

Human papillomavirus (HPV) is a causative agent for a subset of oropharyngeal cancer (OPC). The current standard of care (SOC) for locally advanced OPC is 70 Gy definitive radiotherapy (RT) concurrent with cisplatin, which entails significant proportions of acute and late grade 3 or higher toxicities. Accordingly, discovery of favorable prognosis of HPV-related OPC has led to enthusiasm to attenuate subspecialties therapy in multidisciplinary treatment. Diverse deintensification strategies were investigated in multiple phase 2 trials with an assumption that attenuated treatments result in comparable oncologic outcome and less toxicities compared with SOC. Several trials on chemotherapy deintensification revealed that concomitant administration of cisplatin is not to be omitted or substituted for cetuximab without compromising progression-free survival or local control. A transoral robotic surgery (TORS) is investigated as alternative local treatment, but TORS plus SOC or mild deintensified adjuvant RT showed similar toxicities and inferior oncologic outcomes compared with SOC definitive RT or moderately deintensified RT. However, it has been reported that TORS plus deintensified 30-36 Gy adjuvant RT results in excellent outcome and less late toxicity compared with SOC adjuvant RT. Several phase 2 trials reported apparently equivalent progression-free survival and local control and similar adverse effects with moderately deintensified 60 Gy RT compared with SOC 70 Gy RT. Further dose reduction below 60 Gy has been investigated using biology-directed approaches, which use response to induction chemotherapy or metabolic images to triage HPV-positive OPC for deintensified RT. In summary, these trials provide valuable insights for future directions. Available evidence consistently showed that moderately deintensified RT is effective and safe for HPV-positive OPC in both definitive and adjuvant settings. Concurrent cisplatin remains an essential component without which progression-free survival is significantly compromised for advanced HPV-positive OPC. A simple incorporation of TORS to SOC may be detrimental for oncologic outcome without anticipated toxicity reduction. Given the lack of level 1 evidence, it is prudent to curb an unjustified deviation from the current SOC and limit any deintensified strategies to clinical trials and adhere to the current SOC.

The Impact of Surgical Advancement of Transoral Robotic Surgery on the Safety of Patients

Transoral robotic surgery (TORS) is a relatively new technological advancement in the surgical field of otolaryngology. However, there are many concerns of affordability, safety, patient expectations, and consent. This paper examines how the new surgical technology comes with a price many hospitals cannot afford, potentially compromising patient safety to gain a return on their investment. We analyze patient’s expectations as a reason for risking their safety because there are certain cosmetic standards patients adhere to and opt for minimally invasive procedures, but put themselves in harm's way. We detail out the topic of informed consent, whereby surgeons cannot perform surgery and limit patients’ treatment options. Finally, this paper also examines the role of the FDA in ensuring the safety and efficacy of the TORS technology.

Compliant and Flexible Robotic System with Parallel Continuum Mechanism for Transoral Surgery: A Pilot Cadaveric Study

As one of the minimally invasive surgeries (MIS), transoral robotic surgery (TORS) contributes to excellent oncological and functional outcomes. This paper introduces a compliant and flexible robotic system for transoral surgery, consisting of an execution part with flexible parallel mechanisms and a positioning part with a continuum structure. A pilot cadaveric study that mimics the procedure of the TORS using an intact cadaveric human head was conducted to evaluate the feasibility and efficiency of this robotic system. Both the initial setup time and the time cost by the robot to safely access the deep surgical area in the upper aerodigestive tract are shortened due to the enlarged workspace, compact structure, and increased flexibility. The proposed surgical robotic system is preliminarily demonstrated to be feasible for TORS, especially for the in-depth surgical sites in the upper aerodigestive tract.

Surgical Treatment Options for Epiglottic Collapse in Adult Obstructive Sleep Apnoea: A Systematic Review.

The critical role of epiglottis in airway narrowing contributing to obstructive sleep apnoea (OSA) and continuous positive airway pressure (CPAP) intolerance has recently been revealed. This systematic review was conducted to evaluate available surgical treatment options for epiglottic collapse in adult patients with OSA. The Pubmed and Scopus databases were searched for relevant articles up to and including March 2022 and sixteen studies were selected. Overall, six different surgical techniques were described, including partial epiglottectomy, epiglottis stiffening operation, glossoepiglottopexy, supraglottoplasty, transoral robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. All surgical methods were reported to be safe and effective in managing selected OSA patients with airway narrowing at the level of epiglottis. The surgical management of epiglottic collapse can improve OSA severity or even cure OSA, but can also improve CPAP compliance. The selection of the appropriate surgical technique should be part of an individualised, patient-specific therapeutic approach. However, there are not enough data to make definitive conclusions and additional high-quality studies are required.

The role of the speech and language therapist in the rehabilitation of speech, swallowing, voice and trismus in people diagnosed with head and neck cancer.

Head and neck cancer (HNC) and its treatment can have a significant impact on physical and psychosocial wellbeing. A multidisciplinary team (MDT) approach is critical to reduce the potential acute, long-term and late effects of treatment by optimising function at baseline, supporting people during treatment and with rehabilitation post treatment. The key focus for speech and language therapists is to support the holistic needs of people with a focus on speech, swallowing, voice and mouth opening. Effective management is reliant on working with MDT members and interventions are implemented against the background of robust multidimensional baseline evaluation. There have been significant advances in treatment modalities for both primary and recurrent HNC. These include highly conformal radiotherapy modalities, including: image-guided radiotherapy; parotid-sparing and dysphagia-optimised intensity-modulated radiotherapy; and the introduction of intensity-modulated proton therapy, as well as immunotherapy, transoral robotic surgery and surgery with advanced reconstructive techniques. Such treatment advances coupled with a changing patient demographic means that people with HNC are now living longer. However, this is not always without consequences and late treatment effects are a new challenge facing MDTs, requiring high levels of support and rehabilitation.

Global trends and hotspots in research of robotic surgery in oncology: A bibliometric and visual analysis from 2002 to 2021.

With the development of robotic surgery in the field of oncology, an increasing number of relevant research papers have been published. In order to explore the research hotspots and trends in this field, a bibliometric and visual analysis was performed for the first time. The literature records related to oncology robotic surgery were obtained from the Web of Science Core Collection database and imported into the software VOSviewer 1.6.18, CiteSpace 6.1.R3, and the Bibliometric Online Analysis Platform for analysis. A total of 6,964 publications, including 5,635 articles and 1,329 reviews, were included in this study. Over the past 20 years, annual publications and citations have experienced rapid growth, particularly in the last two years. The United States was the country with the most publications, while Yonsei University in South Korea was the most productive institution. The Journal of Robotic Surgery and the Journal of Urology were the journals with the most publications and citations, respectively. Mottrie A from Belgium and Ficarra V from Italy were the authors with the highest number of publications and citations, respectively. The keywords "robotic surgical procedure", "laparoscopic surgery", "prostate cancer", "colorectal cancer", "gastric cancer", "resection", "complications classification", "open surgery", "transoral robotic surgery", "pathological outcomes", and "robot-assisted surgery" reflect the research hotspots and trends of oncology robotic surgery. The therapeutic advantages of robotic surgery in oncology are not yet prominent, and further randomized controlled trials with multicenter and large samples are needed to evaluate the advantages of robotic surgery compared with laparoscopic surgery and open surgery in the treatment of tumors from multiple outcome indicators.

The Flex Robotic System in Head and Neck Surgery: A Review.

The Flex Robotic System is a device intended for robot-assisted visualization and surgical site access to the head and neck. The aim of this review is to summarize the current knowledge about the Flex Robotic System in head and neck transoral robotic surgery (TORS). The primary search was performed using the term "Flex Robot" across several databases (PubMed, Embase, Cochrane, Scopus). Patients were treated for both benign and malignant diseases. The oropharynx was the most frequent site of disease, followed by the supraglottic larynx, hypopharynx, glottic larynx, oral cavity, and salivary glands. Most of the studies did not reveal major intra- or post-operative complications. Bleeding incidence was low (1.4-15.7%). Visualization of the lesion was 95-100%, while surgical success was 91-100%. In conclusion, lesions of the oropharynx, hypopharynx, or larynx can be successfully resected, thus making the Flex Robotic System a safe and effective tool, reducing the morbidity associated with traditional open surgery.

Surgical management of head and neck cancers: implications for dental practitioners.

Surgery remains an important, often primary, treatment modality in the management of head and neck cancers (HNCs). Malignant disease of the oral cavity, oropharynx and larynx may all be treated by surgery alone, or in combination with chemotherapy and/or radiotherapy.Recent decades have seen significant advances in the surgical management of HNC. Refinement of surgical technique (particularly in microvascular surgery), improved training standards, advances in peri-operative care and more recent innovations, including transoral robotic surgery, have resulted in better survival and quality of life outcomes.This paper provides the dental practitioner with an overview of common surgical procedures used in the management of HNC, with an emphasis on the management of squamous cell cancers affecting the oral cavity, oropharynx and larynx. Throughout, there is an emphasis on the implications for the dental team of cancer and its surgical management, at each of these anatomical sites.

Surgical clinical trials for HPV-positive oropharyngeal carcinoma.

The treatment of HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) continues to evolve as multiple ongoing and recently completed clinical trials investigate the role of surgery, radiation therapy, chemotherapy, and immunotherapy. Current trials are investigating transoral robotic surgery (TORS) in treatment de-escalation protocols in an effort to optimize quality of life, while maintaining historical survival rates. The advantage of TORS is its minimally invasive approach to primary resection of the tumor as well as valuable pathologic staging. The ORATOR trial reported poorer quality of life in patients treated with TORS compared to primary radiotherapy though this was not a clinically meaningful difference. The recently published ECOG 3311 trial showed that surgery can be used to safely de-escalate the adjuvant radiation dose to 50 Gy in intermediate-risk patients. In this review, we summarize and discuss the past and current clinical trials involving surgery in the treatment of HPV-positive OPSCC.

O4.1 Role of the PuraBond haemostatic agent in Trans oral Robotic surgery – A case series

O4.1 Role of the PuraBond haemostatic agent in Trans oral Robotic surgery – A case series

Human Papillomavirus-Associated Head and Neck Cancers. Where are We Now? A Systematic Review.

Human papillomavirus targets the skin and mucous membranes, producing benign hyperplastic lesions and precancerous and cancerous lesions. An increasing number of head and neck cancersin particular, oropharyngeal squamous cell carcinoma, laryngeal squamous cell carcinoma, and oral squamous cell carcinoma, are attributable to HPV infection. HPV-induced HNCs typically affect younger, nonsmoking patients with no prior history of heavy alcohol use, more extensive sexual history, and higher socioeconomic status. The purpose of the review is to present the most recent and well-established findings concerning HPV-induced head and neck cancers and consequently to provide medical specialists with essential information regarding the epidemiology, the role of HPV in HNC cancerogenesis, prevention, diagnosis, and treatment. All authors independently have searched The EMbase, Medline/Pubmed, and Cochrane databases by using the following keywords "head and neck cancer", "human papillomavirus", "HPV", "HPV biology", "oropharyngeal squamous cell carcinoma", "carcinogenesis", "transoral surgery", "robotic surgery". The last search was conducted in March 2022. The references of the publications of interest were also screened for relevant papers. There were no limitations in regard to the publication date. Aiming to avoid the epidemic of HPV-induced HNC, it is paramount to improve the access to vaccination as well as resolve parental concerns regarding vaccine safety. Physicians should rely on reduced-dose radiation and aim to reduce the overall treatment time. Thanks to a more elaborate understanding of the genomic background of HPV-induced HNC, precision medicine could become a relevant part of patients' management. In comparison to traditional techniques and non-operative treatment, transoral robotic surgery (TORS) offers similar oncologic and functional outcomes, with a possible benefit on long-term quality of life. However, more research is needed to establish clear guidelines indicating when TORS resections should be supported with adjuvant therapy.

Consensuses, controversies, and future directions in treatment deintensification for human papillomavirus-associated oropharyngeal cancer.

The most common cancer caused by human papillomavirus (HPV) infection in the United States is oropharyngeal cancer (OPC), and its incidence has been rising since the turn of the century. Because of substantial long-term morbidities with chemoradiation and the favorable prognosis of HPV-positive OPC, identifying the optimal deintensification strategy for this group has been a keystone of academic head-and-neck surgery, radiation oncology, and medical oncology for over the past decade. However, the first generation of randomized chemotherapy deintensification trials failed to change the standard of care, triggering concern over the feasibility of de-escalation. National database studies estimate that up to one third of patients receive nonstandard de-escalated treatments, which have subspecialty-specific nuances. A synthesis of the multidisciplinary deintensification data and current treatment standards is important for the oncology community to reinforce best practices and ensure optimal patient outcomes. In this review, the authors present a summary and comparison of prospective HPV-positive OPC de-escalation trials. Chemotherapy attenuation compromises outcomes without reducing toxicity. Limited data comparing transoral robotic surgery (TORS) with radiation raise concern over toxicity and outcomes with TORS. There are promising data to support de-escalating adjuvant therapy after TORS, but consensus on treatment indications is needed. Encouraging radiation deintensification strategies have been reported (upfront dose reduction and induction chemotherapy-based patient selection), but level I evidence is years away. Ultimately, stage and HPV status may be insufficient to guide de-escalation. The future of deintensification may lie in incorporating intratreatment response assessments to harness the powers of personalized medicine and integrate real-time surveillance.

The Effect of Tumor Margin Status on Progression-Free Survival (PFS) in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC) after Transoral Robotic Surgery (TORS)

<h3>Purpose/Objective(s)</h3> Human papillomavirus (HPV)-mediated oropharyngeal squamous cell carcinoma (OPSCC) has an excellent prognosis, and many patients are treated with transoral robotic surgery (TORS). It is unclear if adjuvant therapy post-TORS in the HPV-positive population should be guided by the same criteria as HPV-negative OPSCC. We sought to examine post-TORS outcomes from a single institution. <h3>Materials/Methods</h3> From a prospectively collected single institution database of head/neck cancer patients, we retrospectively identified patients with OPSCC who underwent TORS from 2015-2021. Demographic, clinical, and pathologic information including margin status and distance from tumor were assessed. Patients were stratified by tumor margin status (positive and negative tumor margin status). Progression-free survival (PFS) probabilities were estimated using the Kaplan-Meier method. Distributions were compared between groups using the log-rank test statistic. <h3>Results</h3> 163 patients who underwent TORS were selected (152 with HPV-positive tumors) with a median age of 59 years (range, 31-79). Most patients had tonsil primaries (115, 70.6%) and T1-2 disease (T1 72 (44.2%), T2 77 (47.2%)). 131 had negative surgical margins (-SM), 32 had positive surgical margins (+SM). There was no significant difference between the two groups. Median distance from negative tumor margin was 0.5mm (range, 0.5-5). PFS analyses were adjusted for HPV-status and pathological features including PNI and LVI. 2yr PFS for -SM was 98.4% vs 93.8% for +SM (p < 0.005). Outcomes for patients with -SM by adjuvant therapy were (n, 2yr PFS): observation (23, 95.2%), radiation (65, 95.3%), chemoradiation (43, 92.9%, p < 0.005). Outcomes for patients with +SM by adjuvant therapy were (n, 2yr PFS): observation (3 patients declined adjuvant therapy, 66.7%), radiation (8 patients declined concurrent chemotherapy, 94.6%), chemoradiation (21, 91.3%, p < 0.005, limited by majority of patients receiving adjuvant chemoradiation). When examining by tumor margin distance and impact on PFS, each additional millimeter resected from tumor defining -SM increased 2yr PFS by 24.3% starting from 0.5mm until 2.4mm. <h3>Conclusion</h3> +SM post-TORS in a largely HPV-positive population from a single institution portends worse 2yr PFS, with a decrement of approximately 5%. In -SM patients, distance from tumor to margin impacted PFS up to 2.4mm, confirming ECOG 3311 cutoff of 3mm as defining close margins. Thus, +SM and close margins continue to impact outcomes in this good risk-population with early-stage HPV-positive cancer and should inform adjuvant therapy recommendations. Ongoing prospective studies investigating de-escalation of adjuvant therapy post-TORS represent cautious efforts to identify means to reduce toxicity in this population.

A Phase II Study of Volume and Dose De-Intensification Following Transoral Robotic Surgery (TORS) and Neck Dissection for p16+ Oropharyngeal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> Current efforts to de-intensify adjuvant therapy for patients with p16+ Oropharyngeal Squamous Cell Carcinoma (OPSCC) have focused on dose de-escalation (ECOG 3311) or volume reduction (AVOID trial). We conducted this prospective Phase II single institution study combining volume and dose de-intensification, in patients with pT0-T3 pN0-N2c p16+ OPSCC, with the goal of maintaining high rates of locoregional control (LRC) and reducing treatment-related toxicity. <h3>Materials/Methods</h3> Eligible patients had pT0-T3 N0-N2c p16+ OPSCC (per AJCC 7th Ed), s/p TORS and neck dissection, with < 5 positive lymph nodes, who met standard indications for adjuvant radiotherapy +/- chemotherapy. Adjuvant RT was delivered in 25 fractions over 5 weeks. The primary site was spared in patients with pT1-T2 tumors resected with negative margins and no LVI or PNI, as per the AVOID trial. If RT to the primary operative bed was indicated, patients received 50, 52.5, or 55 Gy for negative, close, or positive margins, respectively. The neck level(s) with confirmed pathologic disease received 50 Gy, and areas of minor or macroscopic ENE were boosted to 52.5 or 55 Gy, respectively. Other at-risk ipsilateral nodal regions received 45 Gy. The treated volume of the contralateral neck was reduced to mirror the pathologically involved nodal levels in the ipsilateral neck, and received 45 Gy. Concurrent chemotherapy was according to guidelines, but could be omitted in patients with ENE ≤ 1 mm. The trial was powered to demonstrate 2-year LRC rate > 90%. <h3>Results</h3> 118 patients were enrolled between October 2018 and July 2021. Patient characteristics are detailed in the Table. Median follow up is 23 months (range 6 - 40 months). One patient developed regional recurrence after developing distant metastases (DM). No other patients had locoregional failure (LRF), yielding an estimated 2-year LRC rate of 98.8% (95% CI, 92-99.8%). Eight patients (7%) developed DM, and one patient has died of metastatic disease. The TORS resection bed was spared in 55% of patients; due to proximity to level 2, the median dose to the operative bed in these cases was 32.5 Gy (range 16.5 – 46 Gy). Twenty patients had ENE > 1 mm (considered "high risk" per ECOG 3311) and none had LRF. At one-year post-RT, the median MDASI-HN "difficulty swallowing/chewing at its worst" score was 2 (IQR, 1-3), and "choking/coughing with swallowing at its worst" score was 1 (IQR, 0-3), on a scale from 0 (not present) to 10 (as bad as you can imagine). <h3>Conclusion</h3> The combination of adjuvant RT dose de-intensification over 5 weeks and volume reduction, with omission of the primary site in appropriate patients, and reducing the volume of the treated contralateral neck, appears safe. Additional follow up is warranted and ongoing.