A 38-year-old woman has a 2.2 cm right thyroid nodule with BRAF V600E mutation on molecular testing after an indeterminate FNA (Bethesda IV category). She also has a 0.6 cm right central compartment lymph node on ultrasound. According to ATA 2015 guidelines, which is the most appropriate initial surgical management?

• A Right thyroid lobectomy + isthmusectomy alone
• B Total thyroidectomy + right prophylactic central neck dissection ✓
• C Total thyroidectomy + therapeutic central neck dissection + right lateral selective neck dissection
• D Active surveillance for 6 months before deciding on surgery

Explanation

BRAF V600E mutation in a Bethesda IV (follicular neoplasm) or V/VI nodule significantly increases malignancy risk and predicts papillary thyroid cancer with more aggressive behaviour. ATA 2015 guidelines recommend total thyroidectomy for nodules ≥1cm with high-risk features (including BRAF mutation) or clinical/radiological lymph node involvement. Prophylactic central neck dissection is considered when the primary tumour is T3/T4 or when there is clinical nodal involvement in the central compartment. A 0.6 cm node is suspicious, justifying therapeutic rather than prophylactic central dissection, but lateral neck dissection is only indicated with biopsy-proven lateral node metastasis.

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

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Written and medically reviewed by the StethoPrep medical team.