Objective: To compare efficacy, in terms of disease control/survival in advanced hypopharyngeal and laryngeal lesions, according to treatment strategy (primary surgery, PS or primary chemoradiotherapy, CRT) and invasion pattern (cartilage, CAI or soft tissue involvement, STI). Methods. Records; from 463 patients with T3 and T4a carcinoma with CAI (n = 221) or STI (n= 242) treated at a university clinic over 18 years were retrospectively reviewed. Results: Disease-specific survival (DSS) for the CAI group was 70.1% (PS) and 38.4% (CRT), and 76.6% and 46%. for the STI group, respectively. Overall survival (OS) for STI was 56.4% (PS) and 30.6% (CRT), and for CAI 51.1% (PS) and 28.5% (CRT) respectively. Positive resection margins and regional neck metastases reduced survival. T3 lesions treated non-operatively still had significantly improved survival versus T4a by >20%. Conclusion: Surgery remains an indispensable part of treatment in local advanced hypopharyngeal and laryngeal cancer with high survival results. It should be part of a concept that includes adjuvant (C)RT. For T3 lesions, primary CRT is also acceptable and CAI is not a contraindication for primary CRT. Regional disease is a strong prognostic factor. In spite of adjuvant treatment, DSS deteriorates by about 20% in cases with positive resection margins. (C) 2016 Elsevier Ireland Ltd. All rights reserved.