TL + PORT has traditionally been the gold standard in management of ALHC. However, this results in permanent tracheostomy and a possible loss of speech. In case of partial laryngectomy and even in case of TL, there are various options of voice rehabilitation but the successes of all these procedures are highly variable. In 1980s several authors reported interesting possibility of LP with ICT. The first randomized study (RCT) came from VA group who randomized patients to receive either 2 cycles of ICT + RT Vs surgery +PORT. Patients with more than PR received a 3rd cycle followed by definitive RT. There were more local recurrences and fewer distant metastases in the ICT arm. Of the 166 ICT patients, nearly 1/3rd required salvage TL with ultimate LP in 66% surviving patients. These results proved that ICT and definitive RT can be effective in LP without compromising overall survival. European Organization for Research and Treatment of Cancer (EORTC) study randomly assigned hypopharynx cancer patients to receive either immediate surgery with PORT (arm 1) or ICT. Patients with a CR after 2 or 3 cycles of CT were treated there after by RT. Locoregional failures occurred at approximately the same frequencies in both arms but there were fewer distant failures in the ICT arm. The median survival was found to be similar in both arms with LPR of 35% in the ICT arm. This study showed the feasibility of LP in patients with cancer of the hypopharynx. A smaller trial from MSKCC15 reported 52% LPR and another European RCT reported poorer survival in the CT arm with LPR of 20% only. The latter trial had a smaller number of patients and imbalance in randomized groups (4 out of 5 stage IV patients got randomized into CT arm) that could have flawed the outcome. The 3 RCTs (excluding MSKCC trial) were compiled by MACH-NC to obtain a meta analysis that showed similar disease free survival and a non significant trend of higher 6% survival in pooled surgery arm which was counterbalanced by LPR of 58% in the pooled CT arm. Quality of life measures performed as part of the VA study demonstrated that LP offers better speech, good communication skills, lesser pain and depression compared to surgery.