By Dr. Laureano Giraldez-Rodriguez, MD, FACS
One of the questions patients ask me most often is: “Doctor, I have a thyroid nodule — do I need surgery?” And the answer is never simple. The decision between operating and watching is one of the most important ones we make in managing thyroid disease, and it needs to be individualized, well-informed, and shared between doctor and patient.
The thyroid and its nodules: some necessary context
Thyroid nodules are extremely common. With the increasingly frequent use of imaging studies like ultrasounds, CT scans, and MRIs, we’re now detecting thyroid nodules that used to go unnoticed. This has created an interesting phenomenon: we have more diagnoses, but not necessarily more disease that needs treatment.
The vast majority of thyroid nodules, more than 90%, are benign. But that statistic doesn’t necessarily ease the anxiety of a patient who just got their ultrasound results. That’s why it’s essential to understand when a nodule needs more than just observation.
When is thyroid surgery recommended?
Indications for thyroid surgery fall into several categories. The first and clearest indication is a confirmed diagnosis of thyroid cancer. If a fine-needle aspiration biopsy shows malignant cells, surgery is generally the first-line treatment. The extent of the surgery, whether half or all of the thyroid is removed, depends on the type of cancer, its size, and other factors.
The second indication is when the biopsy shows indeterminate or suspicious results. Not every biopsy gives a clear benign or malignant result. There’s a gray zone where the cells look abnormal but not definitively cancerous. In these cases, depending on the biopsy category, a diagnostic lobectomy may be recommended, where half the thyroid is removed to get a definitive diagnosis through complete analysis of the tissue. Molecular genetic testing on the biopsy sample can help in these cases avoid unnecessary surgery.
The third indication is when the nodule or an enlarged thyroid gland causes significant symptoms: compression of the trachea that makes breathing difficult, compression of the esophagus that makes swallowing difficult, or a goiter that extends into the chest.
The fourth indication is hyperthyroidism that doesn’t respond to medical treatment, or when the patient prefers a definitive solution. And the fifth, less urgent but still valid, is cosmetic concern over a visible goiter.
When is it appropriate to watch?
Active surveillance, also called observation, is a perfectly valid and increasingly accepted strategy in certain scenarios. Small nodules with a benign biopsy are ideal candidates for surveillance. We recommend repeating the ultrasound periodically, generally every 12 to 24 months, to monitor for growth or changes in the nodule’s characteristics.
Even some papillary thyroid microcarcinomas, small thyroid cancers under 1 centimeter, can be candidates for active surveillance in selected patients. This approach, pioneered in Japan, is based on evidence that many of these small cancers never grow or spread, and surgery can be done later if growth is observed, without affecting the prognosis.
Nodules that cause minimal symptoms or that don’t have suspicious features on ultrasound can also be safely watched. And as an intermediate alternative, radiofrequency ablation, which we offer at our center, can be an option for symptomatic benign nodules that allows patients to avoid surgery.
What factors personalize the decision?
Beyond the medical indications, there are personal factors that influence the decision. The patient’s age is relevant: in a young patient with a suspicious nodule, we can be more aggressive because they have their whole life ahead of them. The presence of risk factors such as a family history of thyroid cancer or a history of neck radiation exposure during childhood increases our vigilance. The patient’s medical comorbidities can make surgery riskier. And just as important, patient preference: some patients can’t feel at ease with a nodule in their neck and prefer to have it removed even if it’s benign, while others prefer to avoid surgery at all costs.
My philosophy as a surgeon
I firmly believe that the best surgeon isn’t the one who operates the most, but the one who knows when to operate and when not to. My job is to give you the most complete and up-to-date information possible, explain your options clearly, and guide you toward the best decision for your particular case.
I will never operate on you just to operate. But I also won’t leave you at ease when there are signs that something needs attention. That balance is what I look for in every consultation, and it’s what my patients deserve.
If you’ve been diagnosed with a thyroid nodule and aren’t sure what the next step is, come in for an evaluation. A well-grounded second opinion can give you the clarity and peace of mind you need.
