BackgroundIn T4a laryngeal cancer with thyroid cartilage invasion, no optimal frontline treatment has yet been defined in controlled trials.MethodsWe reviewed data from 89 patients with T4a laryngeal cancer featuring thyroid cartilage invasion who were treated initially with either total laryngectomy (n = 53) or a larynx-preservation strategy (n = 36).ResultsThe median progression-free survival (PFS) of the total laryngectomy group had not been attained at the time of analysis and was thus significantly longer than that of the larynx-preservation group (8.7 months). The median overall survival (OS) of patients who underwent total laryngectomy was 87.2 months, significantly longer than that of the larynx-preservation group (31.3 months). The survival benefit of primary surgery compared to a larynx-preservation strategy was more striking in patients of lower N classifications.ConclusionTotal laryngectomy may be a better therapeutic option to treat T4a laryngeal cancer featuring thyroid cartilage invasion, especially in patients exhibiting limited nodal involvement (N0/N1). (c) 2016 Wiley Periodicals, Inc. Head Neck, 2016 (c) 2016 Wiley Periodicals, Inc. Head Neck 38:1271-1277, 2016