Highlight
• Level VII lymph node metastasis occurs in 4.7% of medullary thyroid cancer patients and is associated with aggressive tumor characteristics and poorer survival outcomes.
• Patients with level VII metastasis have significantly worse disease-specific survival compared to those with N1a and N1b classifications.
• The current AJCC Eighth Edition classifies level VII metastasis as N1a; however, reclassifying it as N1b enhances prognostic discrimination and staging accuracy.
• Improved staging stratification may guide more tailored clinical management and follow-up strategies for medullary thyroid cancer.
