ATA Guidelines Tools

7 Treatment Î Patients with MTC and no evidence of neck lymph node metastases by US examination and no evidence of distant metastases should have a total thyroidectomy and dissection of the lymph nodes in the central compartment (level VI). (B) Î In patients with MTC and no evidence of neck metastases on US, and no distant metastases, dissection of lymph nodes in the lateral compartments (levels II-V) may be considered based on serum Ctn levels. Note: The Task Force did not achieve consensus on this recommendation. (I) Î Patients with MTC confined to the neck and cervical lymph nodes should have a total thyroidectomy, dissection of the central lymph node compartment (level VI), and resection of the involved lateral neck compartments (level II-V). When preoperative imaging is positive in the ipsilateral lateral neck compartment but negative in the contralateral neck compartment, contralateral neck dissection should be considered if the basal calcitonin level is greater than 200 pg/mL. (C) Î In the presence of extensive regional or metastatic disease, less aggressive surgery in the central and lateral neck may be appropriate to preserve speech, swallowing, parathyroid function, and shoulder mobility. External beam radiotherapy (EBRT), systemic medical therapy, and other nonsurgical therapies should be considered to achieve local tumor control. (C) Î Following unilateral thyroidectomy for presumed sporadic MTC completion thyroidectomy is recommended in patients with a RET germline mutation, an elevated postoperative serum Ctn level, or imaging studies indicating residual MTC. (B) Note: The presence of an enlarged lymph node in association with a normal serum Ctn level is not an indication for repeat surgery. Î In patients having an inadequate lymph node dissection at the initial thyroidectomy a repeat operation, including compartment oriented lymph node dissection, should be considered if the preoperative basal serum CTN level is <1,000 pg/mL and ≤5 metastatic lymph nodes were removed at the initial surgery. (C) Î During a total thyroidectomy for MTC, normal parathyroid glands should be preserved in situ on a vascular pedicle. Note: If all normal parathyroid glands are resected, or if none appears viable at the termination of the procedure, slivers of a parathyroid gland should be transplanted into the sternocleidomastoid muscle in patients with sporadic MTC, MEN2B, or MEN2A and a RET mutation rarely associated with HPTH. In patients with MEN2A and a RET mutation associated with a high incidence of HPTH the parathyroid tissue should be transplanted in a heterotopic muscle bed.

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