In recent years, along with the suspicion of adding too much iodized salt, people have become more and more concerned about thyroid disease, and once they find out they have thyroid nodules, they worry about cancer. Professor Xiao Haipeng, Secretary of the Party Committee of the First Hospital of Sun Yat-sen University and chief expert of the Department of Endocrinology, pointed out that people have a great misunderstanding about thyroid nodules. In fact, thyroid nodules have a high incidence in the population, but the proportion of malignant nodules is low, accounting for only about 5%, and more than 95% of people have benign nodules, so surgery is not a must. Therefore, there is no need to panic when thyroid nodules are detected, and it is not always necessary to get rid of everything; one needs to be wary of overtreatment. Analysis of causes Blaming high iodine intake and excessive work pressure is actually a misconception. 37-year-old Ms. Wang works as a manager in an advertising company. During a recent physical examination organized by her company, she was found to have “bilateral thyroid nodules, partly with liquefaction, and the right nodule with calcification, with abundant blood flow signals around the nodule, and no abnormal enlarged lymph nodes on both sides”. She was very worried and asked her doctor to remove the nodules in order to prevent future problems. In fact, there is no need to panic when a thyroid nodule is detected. It is very common and more than 95% of people have benign nodules, so surgery is not a must. Professor Xiao Haipeng explained that with the help of high-resolution ultrasound, the detection rate of nodules in healthy people can be as high as 20 to 76 percent, and about 10 percent of nodules can be palpated during physical examination. Studies have shown that only 4 to 6.5 percent of thyroid nodules are malignant. Benign nodules include multinodular (sporadic) goiters, lymphocytic thyroiditis, cysts, follicular adenomas, and others. Many people attribute the appearance of nodules to high iodine intake and excessive work stress, which is also a misconception. “Excessive stress and chronic emotional tension can be a trigger for hyperthyroidism, but not the cause of thyroid nodules.” Xiao Haipeng points out that existing studies show that the appearance of thyroid nodules is not directly related to high iodine intake, and that iodine deficiency can also cause thyroid nodules. Benign nodules sometimes result from chronic inflammation, and some causative causes have not been identified. If a thyroid nodule is suspected on palpation during physical examination, or if a thyroid nodule is found incidentally during a neck ultrasound, CT, MRI, or FDG-PET, a second thyroid ultrasound should be performed. Studies have shown that in patients with thyroid abnormalities found on physical examination who underwent additional ultrasonography, 63% had different findings from palpation, and 24% had additional nodules found. Xiao Haipeng pointed out that to determine the benignity or malignancy of a nodule, a combination of factors is needed. First of all, we should look at the medical history and performance. If you have received radiation exposure in your childhood, if you have a family member with thyroid cancer, if the nodule is rapidly growing, hard and fixed, and if it is accompanied by persistent hoarseness, dysphonia and dysphagia, you should be alert to the possibility that the nodule is malignant. Secondly, it is important to look at the ultrasound examination results. When you get the ultrasound report, many people will be shocked to see “thyroid nodule” written on it. The long list of medical terms such as “microcalcification, coarse calcification, spongy pattern, hypoechoic” written after it is confusing to understand what it means. There are some key words in the ultrasound report that can help patients to understand whether the nodule is benign or malignant. If the ultrasound result states “hyperechoic, coarse calcification (except for medullary thyroid carcinoma), abundant blood flow around the nodule (with normal thyrotropin), spongy pattern, and comet tail sign behind the nodule”, it often indicates that the nodule is benign and there is no need to panic. If there are words like “microcalcifications, hypoechoic, nodules with abundant internal blood supply and disorganized distribution, irregular border, incomplete surrounding halo, anterior-posterior diameter greater than left-right diameter in cross-section”, it means the possibility of thyroid cancer is higher and further examination is needed. For example, in the above mentioned Ms. Wang’s examination report, she has “calcification of the right nodule and blood supply around the nodule”, which is a suspicious case and needs further examination to exclude the possibility of malignancy rather than immediate surgery. Some patients who are suspected of thyroid cancer are operated without close examination, but the result is a benign lesion, which is not uncommon. Xiao Haipeng pointed out that the most reliable way to determine whether a nodule is malignant or benign and whether surgery is needed is to perform a fine or coarse needle puncture on the nodule and take a small amount of tissue for pathological examination and diagnosis. Patients are often resistant when they hear that a puncture is required. “Fine needle aspiration puncture is commonly performed with a 25-gauge needle, which is safe and easy to operate, and is one of the most commonly used methods that can be performed with or without local anesthesia.” Xiao Haipeng points out that fine needle aspiration is not very risky, and only a very small number of patients experience local swelling and pain or bleeding or infection. Some patients with mixed nodules or those located in the posterior thyroid lobe will require ultrasound-guided puncture to avoid misdiagnosis. Patients should also undergo ultrasound-guided fine-needle aspiration biopsy when they have a history of high-risk thyroid malignancy or when ultrasound suggests signs of suspected malignancy, as long as the nodule is greater than five millimeters in diameter. High-risk history of thyroid cancer includes a first-degree relative with thyroid cancer, a history of external radiation treatment as a child, a history of radiation exposure as a child or adolescent, and thyroid cancer detected during a partial thyroidectomy in the past. However, there are four cases in which a puncture biopsy is not necessary. The first is a “hot nodule” confirmed by thyroid nuclide imaging, and the second is a purely cystic nodule suggested by ultrasound. Third, nodules that are highly suspected to be malignant based on ultrasound images. Fourth, the nodule is less than one centimeter in diameter, and there is no malignant sign on ultrasound. The malignant nodules should be surgically removed as soon as possible and after the surgery, thyroxine should be taken for life for suppressive treatment. In the case of benign nodules, it may not always be necessary to get rid of everything. Some patients who blindly remove benign nodules because of a “fear of cancer” end up with hypothyroidism (i.e., “hypothyroidism”). ”Benign nodules should be monitored for abnormalities in thyroid function.” Xiao Haipeng pointed out that benign nodules with normal thyroid function only need to be monitored regularly and do not need surgery. However, if a benign nodule is combined with hyperthyroidism, as evidenced by elevated triiodothyronine (T3) and thyroxine (T4) indicators, and decreased thyrotropin (TSH), medication, surgery or isotope 131I therapy is required. If hypothyroidism develops after nodule surgery, long-term replacement therapy with levothyroxine (L-T4) is required. Special reminder Benign thyroid nodules can be followed up every 6 months to a year If a nodule is found to be qualitatively suspicious, but the patient resists puncture, it can be reviewed periodically (3-6 months). For thyroid nodules that are diagnosed as benign, follow-up can be done every six months to a year. Xiao Haipeng reminded that patients with benign nodules should pay attention to self-observation and seek immediate medical attention in case of signs such as hoarseness, difficulty in breathing, difficulty in swallowing, nodule fixation, and enlarged lymph nodes in the neck. Doctors remind that there are some tests that do not need to be done in the process of confirming and reviewing the diagnosis. Often people take the medical report with “thyroid nodules” and ask for CT, MRI and whole-body PET-CT to confirm the diagnosis. Xiao Haipeng said, in fact, they are not better than ultrasound in terms of sensitivity and specificity. When patients with benign nodules go to the hospital for follow-up, they need to have their thyroid ultrasound rechecked, and thyroid autoantibodies and thyroglobulin quantification may be of some help in determining the cause of the nodule, but these two tests are of little value in identifying the benignity or malignancy of the nodule.