The absence of cancer cells after a puncture biopsy of a thyroid nodule does not completely rule out cancer, and a surgical nodule excision biopsy is still needed if there is a high degree of suspicion of malignancy on imaging. During thyroid imaging, patients are usually advised to undergo an imaging-guided puncture biopsy of the nodule if there is a high suspicion of malignancy. However, not all puncture biopsies reveal cancer cells. On the one hand, there are cases where the patient’s thyroid nodules are indeed benign and therefore no malignant cells are found. On the other hand, there is also the possibility that the area of malignant cells is not punctured because the nature of the nodule is not necessarily homogeneous and may be different in different parts of the nodule. Therefore, if the biopsy does not puncture cancer cells and the imaging is highly suspicious of malignancy, a surgical nodal excision biopsy may be performed.