AbstractBackgroundMedullary thyroid cancer (MTC) is rare, with poorer outcomes than differentiated thyroid cancer. We aimed to identify areas for improvement in the pre‐operative evaluation of patients with possible MTC in a high‐volume endocrine surgery unit in accordance with current practice guidelines. We hypothesised that the selective use of serum calcitonin (sCT) as a biomarker for possible MTC could guide the extent of initial surgical management.MethodsWe recruited MTC patients between 2000 and 2020 from the Monash University Endocrine Surgery Unit database. Demographics, tumour characteristics, pre‐operative evaluation, operative management, and outcomes were analysed.ResultsOf 1454 thyroid cancer patients, 43 (3%) had MTC. Pre‐operatively, 36 (84%) patients with MTC confirmed on cytology (28, 65%), elevated sCT (6, 14%) or RET mutation (2, 4%). Of these 36 patients, 31 (86%) had optimal extent of thyroidectomy and lymph node dissection (LND). Five (14%) had less than total thyroidectomy due to nerve injury. Thirty‐four patients had compartmental LND. In the 12 (27%) patients with indeterminate or non‐diagnostic cytology, 5 had elevated sCT and were managed as above. None of the remaining seven had LND, thus potentially suboptimal surgery.ConclusionOur findings reflect the rarity of MTC, and the challenges of pre‐operative diagnosis. The addition of sCT may improve surgical planning in patients with indeterminate cytology.