Surgery is an option for those with ACR-TI-RADS grade 4 who have biopsy-proven malignancy, produce compressive symptoms requiring surgery, and have aesthetic concerns. Grade 4 is a risk assessment of thyroid nodules based on the American College of Radiology’s (ACR) TI-RADS (Thyroid Imaging Reporting and Data System) classification, with grade 4 meaning suspected malignancy, which can be further categorized into 4A, 4B, and 4C. Generally, 4A nodules >15mm, adjacent to tissues such as trachea and recurrent laryngeal nerve and >10mm require puncture biopsy; while 4B and 4C nodules >10mm and adjacent to tissues such as recurrent laryngeal nerve and >5mm require puncture biopsy, and the rest can be followed up for observation. If the result of puncture is confirmed as thyroid cancer, radical surgery is required. For patients who are confirmed to be benign by puncture and do not require biopsy, surgery is also required if the nodule produces compression symptoms, such as dyspnea due to compression of the trachea. Some patients may have localized skin elevations and masses visible on visual inspection, and may choose to undergo surgery according to their individual needs. It is recommended that patients seek timely medical attention and choose the appropriate treatment plan based on the condition of the lesion and their individual needs.