For more than 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 alone, or with a planned neck dissection if advanced nodal disease is present. This approach usually leaves the patient with nearly normal swallowing and speech, and provides bilateral coverage of the regional neck and retropharyngeal lymphatics. More advanced lesions often are not controlled with radiation alone and are usually considered for partial or total laryngopharyngectomy if the patient is medically operable. Radiation is usually administered postoperatively in this setting, unless the neck disease is thought to be unresectable, in which case preoperative radiation is given. Recent data have shown that adjuvant chemotherapy administered concomitantly with radiotherapy results in improved cure rates for patients with advanced disease compared with irradiation alone. Time-honored established guidelines are still used, although the edges have become blurred. Therefore, patients with larger primary tumors now may be considered for organ preservation treatment with irradiation and chemotherapy, reserving surgery for salvage situations. The subset of patients with advanced T4 pyriform sinus cancers (in whom cure with chemoradiation would likely result in tracheostomy and/or gastrostomy dependence) may be better served with elective surgery and postoperative irradiation. The definition of this subset of patients is unclear but probably includes patients with significant cartilage destruction and those who require pretreatment tracheostomy. The policy at the University of Florida is to treat essentially all pharyngeal wall cancers with external-beam irradiation alone.