By Dr. Laureano Giraldez-Rodriguez, MD, FACS
One of the questions I get most often from patients is: “Doctor, I have a thyroid nodule, do I need surgery?” And the answer is never simple. The decision between operating and monitoring is one of the most important ones we make in managing thyroid disease, and it must be individualized, well-informed, and shared between physician and patient.
The thyroid and its nodules: necessary context
Thyroid nodules are extremely common. With the increasingly frequent use of imaging studies such as ultrasounds, CT scans, and MRIs, we are detecting thyroid nodules that previously went unnoticed. This has created an interesting phenomenon: we have more diagnoses, but not necessarily more disease that requires treatment.
The vast majority of thyroid nodules, more than 90%, are benign. But that statistical fact does not necessarily ease the anxiety of a patient who has just received their ultrasound results. That is why it is essential to understand when a nodule needs more than just observation.
When is thyroid surgery recommended?
The indications for thyroid surgery can be divided into several categories. The first and clearest indication is when there 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 all biopsies give a clear benign or malignant result. There is a gray zone where cells look abnormal but are not definitively cancerous. In these cases, depending on the biopsy category, a diagnostic lobectomy may be recommended — where half the thyroid is removed to obtain a definitive diagnosis through full tissue analysis. Molecular genetic testing on the biopsy sample can help in these cases to avoid unnecessary surgery.
The third indication is when the nodule or enlarged thyroid gland causes significant symptoms: tracheal compression making breathing difficult, esophageal compression making swallowing difficult, or a goiter extending into the chest.
The fourth indication is hyperthyroidism that does not respond to medical treatment, or when the patient prefers a definitive solution. And the fifth, less urgent but valid, is cosmetic concern over a visible goiter.
When is watchful waiting appropriate?
Active surveillance, also called observation, is a perfectly valid strategy and increasingly accepted in certain scenarios. Small nodules with a benign biopsy are ideal candidates for surveillance. Repeating the ultrasound periodically, generally every 12 to 24 months, is recommended to monitor for growth or changes in the nodule’s characteristics.
Even some papillary thyroid microcarcinomas, very small thyroid cancers under one centimeter, may 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 performed later if growth is observed, without affecting the prognosis.
Nodules that cause minimal symptoms or that have no suspicious features on ultrasound can also be safely monitored. And as an intermediate alternative, the radiofrequency ablation we offer at our center may be an option for symptomatic benign nodules that allows surgery to be avoided.
What factors personalize the decision?
Beyond 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 radiation exposure to the neck during childhood heightens our vigilance. The patient’s medical comorbidities can make surgery riskier. And no less important, the patient’s preferences: some patients cannot live comfortably with a nodule in their neck and prefer to have it removed even if it is benign, while others prefer to avoid surgery at all costs.
My philosophy as a surgeon
I firmly believe that the best surgeon is not 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 will also not leave you at ease when there are signs that something needs attention. That balance is what I strive for in every consultation, and it is 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-founded second opinion can give you the clarity and peace of mind you need.
