Wharry LI of the University of Pittsburgh School of Medicine, USA, recently published an article in World J Surg that explored whether ultrasound and puncture cytology could detect malignancy in thyroid nodules ≥4 cm. They included a total of 382 nodules from 361 patients and found a malignancy rate of 22% (83 nodules). The presence or absence of ultrasound signs of malignancy did not help to identify benign or malignant. Of the 86 nodes without ultrasound signs of malignancy, the malignancy rate actually reached 20%. Of the nodes with benign fine needle aspiration results, the malignancy rate was actually 10.4%. The authors therefore conclude that neither ultrasound nor aspiration cytology can effectively differentiate between benign and malignant thyroid nodules ≥4 cm preoperatively. All of these patients should undergo thyroidectomy.