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AIM: Analyse the impact of aggressive surgical treatment with accurate lymphadenectomy in medullary thyroid carcinoma. MATERIALS AND METHODS: We retrospectively analysed 152 patients affected by medullary thyroid carcinoma, divided in two groups, considering outcome and surgical complications. RESULTS: Primary surgical treatment with thyroidectomy plus central and lateral neck dissection, offers significant reduction in post-operative calcitonin levels, reduced recurrences and limited complications. DISCUSSION: Accurate lymphadenectomy, according to the international guidelines and the main results of clinical studies, is the only treatment combined to total thyroidectomy which offers improved outcome in medullary thyroid carcinoma since inefficacy of chemotherapy and radiotherapy. CONCLUSIONS: Surgery is the unique and fundamental therapy for patients affected by medullary thyroid carcinoma. Extended neck dissection combined to precocious diagnosis and strict follow-up might be considered the standard of treatment of medullary thyroid carcinoma.