The prevalence of thyroid nodules in the population is high. Since the widespread use of ultrasound in clinical practice, the detection rate of thyroid nodules has rapidly increased from 4% to 67% of the population, and the number of outpatients in China has increased dramatically. In 2006, the American Thyroid Association (ATA) developed Guidelines for the Management of Thyroid Nodules and Differentiated Thyroid Cancer based on a large body of evidence-based medical research. The main content can be found in the continuing education article “Strategies for the Management of Differentiated Thyroid Cancer” published in this issue. Given the varying levels of diagnosis and treatment in China, it is difficult to completely copy the ATA Guidelines and it is not in line with the specific situation in China. In view of the large difference between the actual operation and the recommended protocol, how should we regulate and manage? Zhang Bin, Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, China The Guidelines recommend that nodules ≤1cm in diameter without suspicion of cancer do not require any other examination or treatment; the management of nodules >1cm is determined by the results of fine needle aspiration biopsy (FNA). If FNA is not diagnostic, close observation or surgical excision is indicated. About 80-90% of all thyroid nodules are nodular goiter, which is a hyperplastic and degenerative disease of the thyroid tissue, not a tumor, and is not an indication for surgery as seen in the Guidelines. Since the detection rate of thyroid nodules can be as high as 19-67%, it is impossible to operate on every patient with thyroid nodules in China with a population of 1.3 billion. However, due to the low level of ultrasound and cytology diagnosis in most hospitals in China, it is impossible to distinguish between benign and malignant nodules before surgery, so some doctors operate on all patients with thyroid nodules, which not only wastes a lot of medical resources, but also causes different degrees of damage to the patient’s appearance and function. We can only adopt different guidelines for diagnosis and treatment according to the actual level of medical care in different regions and hospitals. Some large hospitals in Beijing, Shanghai and Guangzhou that are in a position to do so can try to align with the assessment methods of the Guidelines, relying mainly on ultrasonography and FNA cytology results to determine whether surgical treatment is needed, and the scope of surgical resection can be guided by the frozen section results during surgery, avoiding the waste and damage caused by overtreatment. Provincial and municipal hospitals can mainly rely on the ultrasonographic features provided by ultrasonography for surgical selection, such as the presence of microcalcifications, hypoechoic solid nodules or abundant blood flow in the nodules, suggesting the possibility of malignancy can be operated directly, and intraoperative then judge the benign and malignant according to frozen section. If the ultrasound diagnosis in the primary unit cannot provide useful information, direct surgery can be considered when the patient has the following manifestations in history and examination: (1) history of radiation exposure to the head and neck; (2) family history of thyroid cancer; (3) fast-growing thyroid nodules; (4) hoarseness; (5) enlarged ipsilateral cervical lymph nodes; (6) single solid nodule in men; (7) age ≥45 or <15; (8) masses >4 cm in diameter; (9) hard nodules; (10) adhesions with The nodules are hard; ⑩ adherence to the periphery and poor mobility, etc. Some people are concerned that nodular goiter may become cancerous in the long term, so they choose surgery. Although nodular goiter can be combined with thyroid cancer, the incidence is only about 1%. However, to date, there is no reliable evidence that nodular goiters can become malignant. It is also believed that because 5-6% of all thyroid nodules are malignant, surgery is performed indiscriminately to avoid delaying treatment in this small percentage of patients, with the consequence that 90-95% of these benign lesions are operated on unnecessarily. Since most thyroid cancers are of the differentiated thyroid type with slow progression and excellent outcome, there is no need for overly aggressive surgical treatment of all thyroid nodules, and most patients can avoid surgery by regular review. Data from large samples confirm that FNA-negative patients have only a 0.6-3% chance of developing thyroid cancer during long-term follow-up, and most of them can be detected and treated promptly. In this issue, 2 articles are published on the management of ectopic thyroid. Is surgery worthwhile if the ectopic thyroid has no signs of tumor and no obvious symptoms? Medical disputes due to loss of thyroid and parathyroid function after surgery are cause for alarm. According to the Guidelines, most differentiated thyroid cancers should undergo total thyroidectomy, except for low-risk patients. However, due to the actual situation in China, total thyroidectomy for most differentiated thyroid cancers may lead to a high level of hypoparathyroidism and consequent medical disputes if the Guidelines are strictly followed. Due to the incomplete training system for physicians in China, standardized surgery on how to preserve the parathyroid glands is not promoted enough, and the surgical approach varies greatly from region to region and even from physician to physician. At this stage, the actual situation in China is that if intraoperative frozen section confirms thyroid cancer, unilateral lobectomy with isthmus is usually done, and total thyroidectomy is only applicable to patients with multiple cancer foci in bilateral lobes or distant metastases ready for isotope treatment. If frozen section is not available during surgery, subtotal thyroidectomy on the nodal side is usually performed in China, and then secondary surgery is performed once the malignancy is confirmed by paraffin section. In the article “Options for reoperation of thyroid cancer” published in this issue, it was found that 50% of the ipsilateral residual lobe had cancerous tissue remaining, 19.6% of the contralateral glandular lobe had cancer, 65% of the primary foci had ipsilateral cervical lymph node metastasis, and 14.5% had contralateral metastasis. Therefore, for differentiated thyroid cancer, the scope of surgery should not be smaller than one side of the glandular lobe plus partial resection style. It should be noted that some units or physicians, due to limitations, indiscriminately use the lobectomy approach for thyroid diseases limited to one lobe, ranging from nodular goiter to medullary thyroid carcinoma. In an era when modern medicine emphasizes that treatment should be individualized, there may be problems of over- and under-treatment. The treatment of thyroid cancer should first distinguish between low-risk and high-risk patients. 10-year survival rate of low-risk thyroid cancer patients can be as high as 95-98%, however, if differentiated thyroid cancer has any of the following adverse factors: (i) age ≥ 45 years, (ii) primary foci T4, (iii) distant metastasis, (iv) incomplete resection, and (v) papillary carcinoma grade II. 10-year survival rate is only 50-70%. Therefore, in hospitals and surgeons who are in a position to do so, a more aggressive total or near-total thyroidectomy with postoperative isotope therapy should be used for high-risk patients to improve their chances of long-term survival. Total thyroidectomy is technically demanding and safe for surgeons experienced and using refined perineural dissection techniques, with an incidence of permanent hypoparathyroidism of 0-2.5%. However, in China, thyroid surgery is generally considered a minor procedure and is mostly performed by junior surgeons, and total thyroidectomy is not a procedure that can be performed by junior surgeons. Therefore, it is not advisable to promote total thyroidectomy for differentiated thyroid cancer in a large scale in the current situation. The key to the management of thyroid nodules is to improve the level of diagnosis of thyroid nodules, mainly thyroid ultrasonography and cytological aspiration diagnostic techniques. The accuracy of good ultrasound in diagnosing benign lesions has been reported to be 86.0% and 82% for malignant lesions. However, most hospitals do not differentiate between benign and malignant thyroid ultrasound diagnosis, then the surgeon can base his or her judgment on the description of the ultrasound examination. The diagnosis of benign occupying lesions is based on: (1) multiple foci; (2) a complete “halo” around the lesion; (3) a regular shape of the lesion with clear borders and uniform internal echogenicity; (4) coarse calcified images; and (5) poor blood flow and predominantly peripheral blood flow. The diagnosis of malignant occupying lesion is based on: ① single nodule; ② irregular morphology of the lesion with poorly defined border; ③ inhomogeneous internal hypoechogenicity; ④ fine sand-like calcification; ⑤ abundant blood flow and predominantly internal blood flow; ⑥ metastatic enlargement of lymph nodes in the neck. Many people worry about the risk of tumor implantation with FNA, but according to the results of tens of thousands of puncture cases abroad, there is no report of implantation. Coarse needle puncture is not recommended because of the risk of bleeding and laryngeal return nerve injury. The accuracy of the puncture site also affects the diagnostic result. For nodules that are obvious on palpation, FNA can be performed directly, and a more accurate method is to puncture under ultrasound guidance, especially for multiple nodules, and ultrasound can select the suspicious solid part for puncture. According to foreign reports, the accuracy of cytologic puncture can reach 94-98%, which can significantly reduce the need for intraoperative frozen sections. We often hear surgeons complain that our cytology diagnosis is not accurate enough and reject puncture requests. However, there is a close relationship between the improvement of diagnosis and the number of puncture cases, so we should consciously write more puncture requests and, at the same time, communicate with cytologists in a timely manner so that mutual improvement can be achieved. For example, punctured follicular cells in Hashimoto’s thyroiditis can show large and abundant nuclei, which can be easily misdiagnosed as thyroid cancer, and if timely communication is made, the level of diagnosis can be improved. With the significant rise in the detection of thyroid nodules, there is a growing concern regarding the diagnosis and management of thyroid nodules. It is necessary to study and understand the ATA Guidelines and to develop our own guidelines tailored to our specific situation, both to provide patients with the treatment they deserve and to reduce unnecessary surgery.