Thyroid Nodules: When to do a needle biopsy

Provided by Darryl Willett, MD

At OhioENT and Allergy Physicians, we see a tremendous number of referrals for thyroid nodules. Many times, the patients are told by their primary care physician that they need a Fine Needle Aspiration Biopsy of their thyroid nodules to determine if they are cancerous or not. We do perform many Fine Needle Biopsies the same day as their initial appointment, but oftentimes, we may defer the biopsy or bypass the biopsy and go straight to surgery. This may confuse the patients who simply assumed that it was mandatory to see the surgeon for a Fine Needle Biopsy.

I would like to educate the public on the rationale that the thyroid surgeon goes through in their mind to determine what the best protocol might be for each patients’ needs. Understanding that in general, only 5% of all thyroid nodules are malignant may put the patient at ease, but there are certain nodule characteristics that may be more alarming and raise the index of suspicion for cancer than others.

  1. Nodules that for sure should be considered for Fine Needle Biopsy the same day as initial office visit with ENT Surgeon:
    • any single nodule between 1.0-1.5 cm in size (when there are not multiple nodules present in the remainder of the thyroid) that can be easily palpated or felt on exam
    • a large, purely cystic nodule (nodule consisting of fluid only) > 1.5 cm that can be easily palpated on exam
    • any single nodule on unhealthy patients whom the surgeon feels would not tolerate surgery well and would be better off monitored for nodule growth (elderly, sickly, significant cardiac/pulmonary/renal disease, etc.)
  2. Nodules that should bypass a Fine Needle Biopsy and go straight to surgery:
    • any nodule > 1.5 cm (the rationale is that once nodules grow larger than 1.5 cm, there is too much sampling error with a skinny little needle which may miss a cancer)
    • patient with a family history of thyroid cancer
    • patients with a history of radiation therapy to their neck region
    • patients that have multiple nodules throughout their thyroid gland where any of the nodules are > 1.5 cm (there are too many nodules to biopsy)
    • nodules that have microcalcifications (especially if the microcalcifications are in the rim of the nodule) since this has a much higher incidence of being cancerous
    • nodules > 1.5 cm that are considered “complex” (contains both a solid and fluid component) since this has a higher incidence of being cancerous
  3. Nodules that can be simply followed with repeat ultrasounds and can bypass Fine Needle Biopsy:
    • elderly or sickly patients (as noted above) and patients on blood thinners who would be too high risk for surgery and do not have a history of radiation to neck, family history of thyroid cancer, no microcalcifications in the rim of the nodule
    • single nodules < 1.0 cm
    • multiple nodules in the thyroid with all of them < 1.0 cm
  4. Patients who need to be scheduled for an Ultrasound-Guided Fine Needle Biopsy through the Radiology Department:
    • nodules that are > 1.0 cm, but cannot be felt on exam by the surgeon
    • nodules that are too close to the carotid artery to be safely biopsied in the office

*These guidelines are the opinion of a thyroid surgeon with 25-years experience and should only serve as a suggestion for planned treatment – each case should be considered individually.

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