Mehta RS of the University of Pittsburgh recently noted in Surgery that for mutation-negative nodules with a puncture result of a follicular lesion, nodule size is an independent predictor of malignancy. He noted that the malignancy rate of a nodule with a puncture result of a follicular lesion is 5-15%, but increases to 85-99% if it is also positive for BRAF, RAS, RET/PTC, or PAX8/PPARγ mutations. However, mutation negativity does not exclude malignancy. So they reviewed 230 nodes that were mutation-negative and had a puncture result of a follicular lesion and found that 12 nodes were malignant (5.2%) and that known clinical risk factors did not predict malignancy. On preoperative ultrasound, 33% of the nodules were found to have ≥1 suspected malignant ultrasound sign. In the end, they were well on their way to finding a larger malignant nodule, and certainly the statistics supported this finding. Therefore, they suggest that mutation-negative lesions with follicular lesions on puncture findings that are also small can be left in place and followed up with close ultrasound. As for how small is small, they noted a result that all 88 mutation-negative <18.5 mm nodules were benign.