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Despite all the talk about de-escalating treatment for low-risk oropharyngeal cancer, many patients with intermediate and high risk disease (RTOG 0129 stratification) still have poor outcomes that are typically driven by locoregional disease failure. In the phase 1 FiGaRO trial, a FDG-PET was obtained after induction chemo. Residual activity within 40% of SUVmax was then used to deliver a simultaneous integrated boost (SIB) of 71.5 Gy in 30 fractions during definitive chemoradiation. 65 Gy and 54 Gy were given to high and low risk volumes with concurrent chemo. The authors sought to keep late grade 3+ mucosal toxicity below 10%. Instead, that number was 19% at 12 months. After a little back-tracking, they decided that rate was actually in a range (15-20%) that’s comparable to many larger trials and meta-analyses. TBL: Moderate dose escalation to the primary tumor for unfavorable-risk oropharyngeal cancer is achievable with moderate rates of late mucosal toxicity. | Michaelidou, Radiother Oncol 2020