A 28-year-old man is found to have elevated calcitonin (320 pg/mL) on routine screening. Fine needle aspiration of a 1.2 cm thyroid nodule reveals medullary thyroid carcinoma (MTC). Genetic testing confirms RET proto-oncogene mutation in codon 634. Which of the following is the MOST appropriate surgical approach?

• A Total thyroidectomy alone
• B Total thyroidectomy with central neck dissection (level VI) ✓
• C Hemithyroidectomy with ipsilateral central neck dissection
• D Total thyroidectomy with bilateral central and lateral neck dissection

Explanation

For clinically node-negative MTC, total thyroidectomy with prophylactic central compartment (level VI) neck dissection is the standard of care. Codon 634 RET mutations (MEN2A) are associated with intermediate–high aggressiveness. Lateral neck dissection (levels II–V) is added when there is clinical or ultrasound evidence of lateral node disease, or when basal calcitonin is very high (>200–400 pg/mL by some guidelines). With a basal calcitonin of 320 pg/mL and cN0 status, most guidelines recommend central dissection ± ipsilateral lateral dissection but the minimum required is total thyroidectomy plus central dissection.

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

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Written and medically reviewed by the StethoPrep medical team.