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We aimed to determine whether pretreatment metabolic tumor volume of the primary tumor (T‐ MTV ) or T classification would be a better predictor of laryngectomy‐free survival ( LFS ) and overall survival ( OS ) after chemoradiotherapy in patients with locally advanced laryngeal or hypopharyngeal cancer requiring total laryngectomy. We analyzed 85 patients using a Cox proportional hazards model and evaluated its usefulness by Akaike's information criterion. A T‐ MTV  cut‐off value was determined by time‐dependent receiver operating characteristic curve analysis. Interobserver reliability for measuring T‐ MTV  was estimated by the intraclass correlation coefficient ( ICC ). After adjustment for covariables, T‐ MTV , irrespective of whether a continuous or dichotomized variable, and T classification remained independent predictors of  LFS  and  OS . Large T‐ MTV  (>28.7  mL ) was associated with inferior  LFS  (hazard ratio [ HR ], 4.16; 95% confidence interval [ CI ], 1.97–8.70;  P  = 0.0003) and inferior  OS  ( HR , 3.18; 95%  CI , 1.47–6.69;  P  = 0.004) compared with small T‐ MTV  (≤28.7  mL ). The T‐ MTV  model outperformed the T classification model in predicting  LFS  and  OS  ( P  = 0.007 and 0.01, respectively). Three‐year  LFS  and  OS  rates for patients with small versus large T‐ MTV  were 68%  vs  9% ( P  < 0.0001) and 77%  vs  25% ( P  < 0.0001), respectively, whereas those for patients with T2‐T3 versus T4a were 61%  vs  31% ( P  = 0.003) and 71%  vs  48% ( P  = 0.10), respectively.  ICC  was 0.99 (95% CI, 0.99–1.00). Given the excellent interobserver reliability, T‐ MTV  is better than T classification to identify patients who would benefit from the larynx preservation approach.

Metabolic tumor volume of primary tumor predicts survival better than T classification in the larynx preservation approach