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Pre-op clinical and radiographic assessment of lymph nodes is crucial to deciding which patients with oropharyngeal squamous cell carcinoma (oSCC) should side-step the scalpel and proceed straight to definitive chemoradiation to avoid tri-modality toxicity. This modern (read: heavy on HPV-positivity) retrospective series of 92 patients with pT1-2 oSCC post-transoral robotic surgery (TORS) and neck dissection aims to quantify how many wind up with nodal extracapsular extension (ECE) or multiple nodes involved buying them adjuvant radiation +/- chemo. 7 of 32 patients (22%) had occult pathologic multi-node involvement, and 5 of 39 (13%) had occult pathologic ECE. For those confused by the denominators, yes well over half were found on central review to have pre-op imaging findings consistent with multi-node involvement or ECE. TBL: In the modern era, imaging isn’t great at ruling out nodal disease that calls for multi-modal therapy for oSCC supporting intriguing arguments for upfront staging neck dissections prior to TORS. | McMullen, JAMA Otolaryngol Head Neck Surg 2019