A 28-year-old woman has a thyroid nodule (1.2 cm). FNAC shows Bethesda Category V (suspicious for malignancy). Molecular testing shows a BRAF V600E mutation. On staging, no lymphadenopathy is present. The most appropriate initial surgical management per ATA 2015 guidelines is:

• A Total thyroidectomy with prophylactic central neck dissection
• B Total thyroidectomy alone (no routine prophylactic central neck dissection for T1)
• C Ipsilateral thyroid lobectomy (hemithyroidectomy) ✓
• D Active surveillance for 6 months before surgery

Explanation

Per ATA 2015 guidelines, for low-risk papillary thyroid carcinoma (unifocal, <4 cm, no extrathyroidal extension, no distant metastases, no high-risk features), thyroid lobectomy alone is acceptable and may be sufficient. BRAF V600E positivity does upstage risk but does not automatically mandate total thyroidectomy for a T1 lesion. Prophylactic central neck dissection is NOT recommended for T1/T2 cN0 disease due to increased complication risk without clear survival benefit. However, the presence of BRAF V600E with Bethesda V suggests PTC, and if total thyroidectomy is chosen, prophylactic central neck dissection may be considered — but lobectomy remains a valid option for T1 N0 disease.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.