Extensive Micrometastatic Burden after Elective Lateral Neck Dissection in Medullary Thyroid Carcinoma with Elevated Preoperative Calcitonin: a Case Report and Literature Review
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Medullary thyroid carcinoma (MTC) is characterized by early lymphatic spread, and preoperative serum markers such as calcitonin and carcinoembryonic antigen (CEA) are key indicators of metastatic burden. We report a 70-year-old man with a right thyroid nodule showing unremarkable findings on CT but markedly elevated preoperative calcitonin (827 pg/mL) and CEA (19.07 ng/mL). Core-needle biopsy revealed MTC, and BRAF V600E testing was negative. Given the disproportionately high biochemical burden suggesting occult nodal metastasis despite negative imaging, total thyroidectomy with elective right lateral neck dissection was performed. Pathology demonstrated a 2.3 cm MTC (pT2) with 28 of 64 lymph nodes positive (pN1b), the largest metastatic deposit measuring 0.8 cm with extranodal extension. Postoperative radiotherapy was completed, and the patient remains disease-free at 10 months. This case suggests that markedly elevated preoperative calcitonin and CEA levels may indicate occult lateral nodal disease even in the absence of radiologic suspicion, and elective lateral neck dissection may be considered in selected high-risk MTC patients.
Abstract
Medullary thyroid carcinoma (MTC) is characterized by early lymphatic spread, and preoperative serum markers such as calcitonin and carcinoembryonic antigen (CEA) are key indicators of metastatic burden. We report a 70-year-old man with a right thyroid nodule showing unremarkable findings on CT but markedly elevated preoperative calcitonin (827 pg/mL) and CEA (19.07 ng/mL). Core-needle biopsy revealed MTC, and BRAF V600E testing was negative. Given the disproportionately high biochemical burden suggesting occult nodal metastasis despite negative imaging, total thyroidectomy with elective right lateral neck dissection was performed. Pathology demonstrated a 2.3 cm MTC (pT2) with 28 of 64 lymph nodes positive (pN1b), the largest metastatic deposit measuring 0.8 cm with extranodal extension. Postoperative radiotherapy was completed, and the patient remains disease-free at 10 months. This case suggests that markedly elevated preoperative calcitonin and CEA levels may indicate occult lateral nodal disease even in the absence of radiologic suspicion, and elective lateral neck dissection may be considered in selected high-risk MTC patients.