Purpose: To determine the outcome of patients with Group III and IV parameningeal rhabdomyosarcoma (PMS) who do not achieve a complete response at the primary site after chemoradiation Material and Methods: From 1965 to 2000, 34 patients with parameningeal RMS were seen at the University of Iowa. Primary sites included the paranasal sinuses in 9, nasopharynx in 8, infratemporal fossa in 7, pterygopalatine fossa in 5, nasal cavity in 2 and mastoid/middle ear in 2. All but 2 patients had embryonal histology. Only 2 (6%) had lymph node metastasis at initial diagnosis. Five patients had surgical resection at initial diagnosis (Group I 2, II 3). The remaining 29 patients (Group III 27, Group IV 2) form the basis of this report. All patients received chemotherapy consisting of vincristine, actinomycin-D and cyclophosphamide (VAC) in 18 (62%), VAC + adriamycin in 6 (21%), VC + adriamycin in 3 (10%) and other in 2. Radiotherapy was given to the primary site. Median dose was 50.4 Gy (range, 41.4–65 Gy. Two had hyper-fractionated RT. Median follow-up time for surviving patients was 215 months (range, 12–378). Results: The 2- and 5-year overall survival rates were 79.1% and 51.7% while the 2- and 5-year freedom from local progression rates were 65.5% and 56.8%. Eighteen pts (62%) had a complete response (CR) at the primary site after chemoradiation. For the 11 pts who did not have a CR at the primary site as determined by physical examination and imaging, 8 underwent surgical resection at 1.5–10 months after RT; the 2- and 5-year post-relapse survival rates for those who had surgical salvage were 100% and 60%. None of the 3 pts who did not have surgical salvage survived. Late effects secondary to the surgical resection were minimal with slight facial asymmetry as the most common late toxicity in 4. Conclusions: Surgical salvage after an incomplete response to chemoradiation in parameningeal RMS is feasible and can be curative in majority of patients.