How would you approach a laryngeal adenoid cystic carcinoma in a patient seeking larynx preservation?

This is a rare case scenario (laryngeal ACC) in a rare cancer (ACC) of an uncommon group of malignancies (primary salivary gland malignancies) for which direct evidence is sparse. I would, therefore, approach with some general principles and a generous pinch of salt in this scenario. The initial treatment for most salivary gland malignancies including ACC is surgery. Having said that, it's probably only in the T1 tumors (non-AC involving) and a few select T2s that can get larynx-sparing conservatory surgery. Where feasible, I'd go with surgery first followed by PORT. In the advanced cases, while surgery is still the best first line for optimizing the local control, patients may want to explore a non-surgical option. Just as for SCC T4 tumor...