Thyroid Nodules: When Should They Be Removed?

Thyroid nodules are abnormal masses that form within the thyroid gland. In most cases, these nodules are benign and cause no symptoms, but in certain situations their presence may require surgery. So, when should you consider removing them? This article answers that question by exploring in depth the nature, symptoms, diagnosis and criteria for removal of thyroid nodules.

What are thyroid nodules?

A thyroid nodule is a solid or fluid-filled mass that develops in the thyroid gland, located at the base of the neck. These nodules can be single or multiple and vary in size. Although 90 to 95% of nodules are benign, their mere presence can cause concern, particularly because of the possibility, however small, of thyroid cancer.

Nodules can be:

• Solid, made up mainly of thyroid tissue.
• Cystic, filled with fluid.
• Mixed, combining both.

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What are the symptoms of thyroid nodules?

In most cases, thyroid nodules cause no symptoms and are discovered incidentally during a routine medical exam or neck imaging. However, some symptoms may appear depending on the size, location and nature of the nodule.

Here are the signs to watch for:

• A visible or palpable lump at the base of the neck.
• A feeling of discomfort or pressure in the neck.
• Difficulty swallowing or breathing, particularly if the nodule is large.
• A hoarse voice or voice changes.
• In some cases, the nodule may be functional, meaning it produces excess thyroid hormones, causing hyperthyroidism. The symptoms then include:
• Unexplained weight loss
• Palpitations
• Irritability
• Heat intolerance

The difference between a thyroid cyst and a thyroid nodule

It is important to distinguish a thyroid cyst from a thyroid nodule:

• A thyroid cyst is a fluid-filled cavity. It may be entirely fluid or contain solid debris (complex cyst).
• A thyroid nodule may be solid, cystic or mixed. The consistency of a nodule is an important criterion for assessing its risk of malignancy.

Whether a nodule is fluid or solid will be determined mainly by thyroid ultrasound.

Diagnosis of thyroid nodules

Diagnosis relies on a set of tests that characterize the nodule and assess the associated risks.

Thyroid ultrasound

This is the first-line examination. Ultrasound makes it possible to:

• Measure the size and shape of the nodule
• Identify its nature (solid, fluid, mixed)
• Detect suspicious signs of malignancy (irregular margins, microcalcifications, internal vascularity, etc.)

Radiologists often use the TIRADS classification (Thyroid Imaging Reporting And Data System) to estimate the risk of cancer.

Laboratory tests

Blood tests assess thyroid function:

• TSH (thyroid-stimulating hormone): its level shows whether the thyroid is underactive, overactive or normal (euthyroid).
• If TSH is low, an iodine scintiscan may be performed to detect a hot nodule (functional) or a cold one (non-functional).

In some cases, a fine-needle aspiration (cytology) is performed to analyze the cells of the nodule. This test is decisive for identifying possible malignancy.

When should a thyroid nodule be removed?

Removal of a thyroid nodule is not automatic. It is considered according to several medical, cosmetic or functional criteria. Here are the main indications for surgery:

1. Suspected or confirmed thyroid cancer
• If fine-needle aspiration reveals suspicious or malignant cells (Bethesda V or VI classification), removal is strongly recommended.
• A hyperechoic nodule with microcalcifications or irregular margins increases the risk of cancer.
2. Large nodule size
• A nodule larger than 4 cm, even if benign, may be removed to avoid mechanical complications (tracheal compression, dysphagia).
3. Compressive or cosmetic symptoms
• When the nodule causes visible or physical discomfort, surgery can improve the patient’s quality of life.
4. Toxic (functional) nodule
• A nodule that secretes hormones autonomously can lead to hyperthyroidism. In this case, several options exist: surgery, radioactive iodine or drug treatment.
5. Rapid growth of the nodule
• A rapid increase in size is suspicious, especially in older people, and warrants a thorough evaluation.
6. Failed or limited follow-up
• In some patients (pregnancy, impossibility of aspiration, multiple nodules), monitoring can be complicated, sometimes justifying preventive surgery.