Thyroid nodules are growths that occur in the thyroid gland forming a lump or bump within the otherwise smooth thyroid surface. Thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Many people are unaware they have thyroid nodules. Some folks need thyroid nodule surgery to treat these abnormal growths or lumps in the thyroid gland. Thyroid nodule surgery involves removing half or the whole thyroid gland in almost all instances.

Here are the top 4 facts about thyroid nodule surgery

1) Thyroid Nodules with Cancer Require Surgery

2) Some Benign (Non-Cancerous) Nodules Need Surgery

3) Multiple Nodules Can Necessitate Surgery

4) Surgery Provides the Most Definitive Diagnosis of the Nodule

Let’s take a more detailed look at all four of these facts about thyroid nodule surgery.

Thyroid Nodule Surgery Fact #1: Thyroid Nodules with Cancer Require Surgery

Most thyroid nodules are benign, but some are cancerous. Thyroid cancer only accounts for approximately 5% (10%-15% at most) of all thyroid nodules. Thyroid surgery is the mainstay of treating thyroid cancer. Thyroid surgery done for thyroid nodules with cancer is often no different than thyroid nodule surgery done for non-cancerous growths in the thyroid. Thyroid nodule surgery done correctly in experienced and skilled hands is crucial for curing thyroid cancer.

Numerous studies have shown that up to 30% of thyroid nodules with cancer have spread to lymph nodes at the time of diagnosis and surgery. Many times, thyroid nodule surgery can cure the cancer by only removing half (or a lobe) of the thyroid (thyroid lobectomy). Again, expert evaluation and complete removal of all cancer with the first surgery are extremely important to avoid complications and leaving cancer behind.

In other instances, total thyroid removal (total thyroidectomy) is needed to treat thyroid nodules with cancer that are large, located in both halves of the thyroid, or when thyroid cancer has spread to lymph nodes in the neck. Again, removal of the lymph nodes behind and around the thyroid in the middle of the neck, at a minimum, is important to ensure the cancer is completely cured. Complete thyroid removal is even riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage. Thus, thyroid nodule surgery involving total thyroid removal should only be done by high-volume, experienced surgeons at busy centers such as ours. Hospital for Endocrine Surgery

For more information about thyroid surgery for cancer, visit our website at www.thyroidcancer.com and check out our blogs on thyroid removal for thyroid cancer at www.thyroidectomy-for-thyroid-cancer, and www.3-best-thyroid-operations-for-thyroid-cancer.

Figure 1: Ultrasound image of a cancerous thyroid nodule

Thyroid Nodule Surgery Fact #2: Some Benign (Non-Cancerous) Nodules Need Surgery

As noted above, thyroid nodules are common, occurring in 40% of women and 30% of men during their lifetime. Most nodules are benign, but some of these do require thyroid nodule surgery. Thyroid nodules are often diagnosed as benign by needle biopsy during a patient evaluation. Although these nodules are benign, almost all of them will enlarge or grow over time. Thus, size is one reason for benign thyroid nodule surgery. Any nodule that is 4 cm or larger should be removed with thyroid nodule surgery. Thyroid surgery is also very frequently needed for nodules that have atypical or suspicious cells on biopsy. This allows for a definitive diagnosis and cure.

Many thyroid nodules that are benign on biopsy may be observed. This is provided that the nodule is not overactive/toxic (causing hyperthyroidism), large (4 cm or greater; or >1.5 inches) or progressing in size, symptomatic, part of a goiter that is extending into the chest cavity, or pushing the windpipe (tracheal) or swallowing tube (esophagus). If one or more of those characteristics are present, then thyroid nodule surgery for treatment is necessary. Observation usually implies repeating thyroid blood tests, ultrasound, and physical examination in approximately 12-18 months (an ultrasound every 3 or 6 months is not indicated for benign nodules).

To learn more about thyroid nodules, visit our blog at www.top-5-worries-about-thyroid-nodules.

Thyroid Nodule Surgery Fact #3: Multiple Nodules Can Necessitate Surgery

Multiple thyroid nodules, particularly when part of an enlarged thyroid (goiter), can require surgery. Even if a nodule, or 2-3 nodules, are benign on needle biopsy, an enlarged thyroid with numerous nodules (multinodular goiter) often requires thyroid nodule surgery for a few reasons. First, it is very hard and impractical to monitor and needle biopsy more than 2-3 nodules. Second, multiple thyroid nodules and goiter often produce symptoms eventually. Symptomatic thyroid nodules require thyroid nodule surgery. The most common symptom or complaint of a multinodular goiter is the unsightly cosmetic appearance of a large lump in the neck or the symptoms produced by the actual size of the goiter. Symptoms related to the size of the goiter may include a sense of a lump in the throat, difficulty swallowing, difficulty breathing, and even in extreme cases, voice changes or a completely hoarse voice. Finally, thyroid nodules or a thyroid goiter that have grown under the collarbone and into the chest cavity (substernal goiter) always require thyroid removal.

One important consideration is that even though a substernal goiter with multiple nodules may extend extensively below the sternum (collar bone) and go well into the chest, these can almost always routinely be removed through an incision in the lower neck right above your collar bone. Skill and experience are key for these challenging thyroid surgeries. If your surgeon is telling you that they need to "split your chest" or "open your sternum", doublecheck to make sure that you have identified a highly- experienced thyroid surgeon. www.top-3-ways-to-find-best-thyroid-surgeon www.multinodular-goiter-substernal

Figure 1: CT scan image of a massive substernal goiter with multiple nodules indicated with orange arrows. The goiter surrounds the windpipe (trachea) which is identified with the blue arrow. The dark black areas on each side represent the lungs.

Thyroid Nodule Surgery Fact #4: Surgery Provides the Most Definitive Diagnosis of the Nodule

Most of the time, a needle biopsy is performed prior to surgery to obtain a diagnosis to guide treatment. Patients should realize that thyroid biopsies are only as good and reliable as the people performing them and the pathologists who are evaluating the cells. The results of a thyroid needle biopsy are categorized according to the Bethesda System for Reporting Thyroid Cytopathology for Thyroid Nodules. The diagnostic categories are as follows:

1. Nondiagnostic or unsatisfactory
2. Benign
3. Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS)
4. Follicular neoplasm or suspicious for a follicular neoplasm
5. Suspicious for malignancy
6. Malignant

Many thyroid nodules cannot be diagnosed as cancerous until the entire nodule has been removed during thyroid nodule surgery where half or the whole thyroid is taken out. Frequently, a needle biopsy before surgery does not yield a definitive diagnosis as to whether a thyroid nodule is cancerous or benign (non-cancerous). Even special molecular genetic testing of thyroid cells from a biopsy often does not reveal whether a nodule is cancer or benign. In some large studies, up to 50% of thyroid cancers are not diagnosed until after thyroid nodule surgery.

Clearly, a biopsy does not always tell the doctor whether thyroid cancer is present. Furthermore, biopsies are not always accurate, and large nodules can harbor cancer (10.4%- 22% of the time) that is not diagnosed with FNA biopsy (or needle biopsy) preoperatively. That is to say that needle biopsies are not perfect, particularly as the nodules get larger. Thyroid nodule surgery can be indicated for a definitive diagnosis and cure.

Summary

Thyroid nodules are very common. Thyroid nodule surgery, involving removal of half or the whole thyroid, is often necessary to diagnose and cure these nodules, particularly when they are cancerous. Large nodules, multiple nodules with or without thyroid goiter (enlarged thyroid), and ones that are atypical or suspicious often require thyroid nodule surgery. Even benign nodules may need surgery depending on symptoms, growth, or size.

Expert evaluation and treatment for thyroid nodules are paramount. Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid nodule surgery. To learn more and become a patient, please see our resources below.

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more  The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.