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3 Î Basal levels of serum Ctn and carcinoembryonic antigen (CEA) should be measured concurrently. In patients with advanced MTC a marked elevation in the serum CEA level out of proportion to a lower serum Ctn level, or normal or low levels of both serum Ctn and CEA, indicate poorly differentiated MTC. (B). Î The assessment of a thyroid tumor with any feature suggestive of MTC should include immunohistochemical (IHC) analysis to determine the presence markers such as Ctn, chromogranin, and CEA, and the absence of thyroglobulin. (B) Î Complete notation of the features of every MTC should follow the synoptic reporting guidelines of the College of American Pathologists Protocol for the Examination of Specimens from Patients with Carcinomas of the Thyroid Gland (www.cap.org). (B) Î In patients with MTC morphological examination of the entire gland is recommended to determine the presence of C-Cell hyperplasia (CCH) or multifocal neoplasia. (C) Î Thyroid nodules that are ≥1 cm in size should be evaluated by fine needle aspiration biopsy (FNA). FNA findings that are inconclusive or suggestive of MTC should have calcitonin measured in the FNA washout fluid and IHC staining of the FNA sample to detect the presence of markers such as Ctn, chromogranin, and CEA, and the absence of thyroglobulin. (B). Î Realizing that opinions of experts vary regarding the usefulness of measuring serum Ctn levels in patients with nodular goiters, the Task Force recommends that physicians decide whether the technique is useful in the management of patients in their clinic. (I) Î Patients presenting with a thyroid nodule on physical examination should have determination of serum levels of Ctn and CEA, and genetic testing for a RET germline mutation. The presence of a PHEO and HPTH should be excluded in patients with hereditary MTC. Î Ultrasound (US) examination of the neck should be performed in all patients with MTC. Contrast enhanced CT of the neck and chest, three-phase contrast-enhanced multi-detector liver CT, or contrast- enhanced MRI of the liver, and axial MRI and bone scintigraphy are recommended in patients with extensive neck disease and signs or symptoms of regional or distant metastases. These studies should also be conducted in all patients with a serum Ctn level greater than 500 pg/mL. (C) Î Neither FDG-PET/CT nor F-DOPA-PET/CT is recommended to detect the presence of distant metastases. (E)

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