Do All Thyroid Nodules Require Surgery?

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Question:

Is it always mandatory to remove a thyroid nodule? Even if there are no cancer cells, and the nodule is benign? I'm so confused with my thyroid nodule. It hasn't enlarged in the last five years. It’s around 2 cm, and a biopsy has shown that it is benign. I also take levothyroxine. Is it necessary to remove the nodule?

Answer:

The simple answer is no, it’s not always mandatory to surgically remove a thyroid nodule. In general, thyroid nodules are very common. One study estimates that as many as two-thirds of us have undetected thyroid nodules. The likelihood of having a thyroid nodule is higher in women, and people over the age of 60. Most thyroid nodules are benign, but it’s recommended that nodules be evaluated to rule out the potential of thyroid cancer.

When you have a thyroid nodule, your doctor will usually follow several steps to evaluate the situation:

  1. Your thyroid stimulating hormone (TSH) level will be measured by blood test.  If your TSH level is not within the reference range, a radioiodine uptake (RAI-U) scan should be performed.
  1. If the RAI-U test identifies your nodule as “cold” and nonfunctioning (more likely to be cancerous), or “warm” and partially functioning (somewhat likely to be cancerous), a fine needle aspiration (FNA) biopsy is recommended.

  2. For most nodules, a thyroid and cervical lymph node ultrasound is recommended.

  3. Ultrasound evaluation can classify your nodule into one of five categories:

  • Benign with zero-percent risk of cancer
  • Very low suspicion, with less than three-percent risk of cancer
  • Low suspicion with five to 10-percent risk of cancer
  • Intermediate suspicion with 10- to 20-percent risk of cancer
  • High suspicion with 70- to 90-percent risk of cancer
  1. If the ultrasound identifies your nodule(s) as low, intermediate, or high suspicion, an FNA is recommended.

  2. If your FNA is benign, the nodule is typically monitored going forward. If the FNA result is “non-diagnostic” — meaning that the results can’t definitively rule out cancer — the FNA is repeated along with cytologic and DNA evaluation, such as the Afirma Thyroid Analysis test.

Most thyroid nodules are not cancerous. These benign thyroid nodules should be periodically monitored for changes. If a benign nodule is affecting your breathing or swallowing or is cosmetically unsightly, however, it may be treated with thyroid hormone replacement medication like levothyroxine, percutaneous ethanol injections (PEI), or high-intensity focused ultrasound ablation (HIFU).

When is surgery recommended for a thyroid nodule?

Thyroid cancer is found in seven to 15 percent of nodules evaluated. When your FNA shows evidence of malignancy, surgery is almost always recommended.

Other cases when surgery to remove a thyroid nodule — or in some cases, the entire thyroid gland — is recommended include:

  • When repeat FNAs and cytologic testing are non-diagnostic or inconclusive
  • If your nodule is benign after FNA but is less than 4 cm and growing
  • If your nodule is benign but is causing compression or structural symptoms, affecting your voice, swallowing, or breathing
  • If your nodule is benign but visible and cosmetically unsightly

In some cases, if you have a small thyroid nodule, and it is found to contain slow-growing and non-aggressive papillary cancer, active surveillance may be recommended instead of surgical removal.

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You should know: The answer above provides general health information that is not intended to replace medical advice or treatment recommendations from a qualified healthcare professional.

See more helpful articles:

Thyroid Nodules: Diagnosis and Treatment

Current Issues in Thyroid Cancer, With Dr. John C. Morris

How to Do a Thyroid Neck Check for Nodules

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