For over 20 years the policy at the University of Florida has been to treat patients with favorable stage T1-T2 pyriform sinus carcinoma by using radiation therapy (RT) alone, or RT combined with a planned neck dissection if advanced nodal disease is present. This approach usually leaves the patient with nearly normal swallowing and speech, and also provides bilateral coverage of the regional neck and retropharyngeal lymphatics. More advanced lesions are not reliably controlled with radiation alone, and have historically been considered for total laryngopharyngectomy if the patient is medically operable.1 Radiation is usually administered postoperatively unless the neck disease is felt to be unresectable initially, in which case preoperative radiation is given. More recently, concomitant radiation and chemotherapy has been established as standard treatm ent for certain advanced-stage tumors with extensive neck disease. Some of these cases may now be treated initially with organ-sparing techniques, reserving surgery for salvage. As a result, recommendations are evolving as to the most appropriate treatment program for selected advanced-stage presentations. Much of the debate centers on the need for neck dissection in stage IVa and IVb patients after initial treatment with high-dose radiochemotherapy. For the subset of patients with advanced T4 pyriform sinus cancers in whom a cure with chemoradiation would likely result in tracheostomy and/or gastrostomy dependence, surgery with postoperative irradiation may still be the preferable option. The definition of this subset of patients is unclear, but probably includes those with significant cartilage destruction and/or a compromised airway requiring pretreatment tracheostomy. Our policy is to treat essentially all pharyngeal wall cancers with primary irradiation, with or without chemotherapy.