Surgical Indication in Thyroid Nodules ≥4 cm: Do Larger Nodules Carry Higher Malignancy and Complication Risks?

Objective: The management of thyroid nodules is outlined in various clinical guidelines. While the American Thyroid Association guideline provides more systematic algorithms for thyroid nodules smaller than 4 cm in diameter, there is no consensus on the management of nodules ≥4 cm. This study aims to contribute to this topic by evaluating the clinical data of patients who underwent thyroidectomy for nodules measuring ≥4 cm.

Methods: This study included 199 patients who underwent thyroidectomy due to thyroid nodules measuring ≥4 cm in diameter. Patients were evaluated based on age, sex, preoperative, postoperative day 1, and at least 1-month postoperative calcium (Ca) and parathyroid hormone (PTH) levels, maximum nodule diameter, fine-needle aspiration biopsy (FNAB) status, and final pathology data.

Results: A total of 199 patients (28 men, 171 women; mean age: 46.52±13.82 y) were included in the study. Malignancy was identified in 17.6% of the cases. Nodule size was significantly larger in male patients (P=0.017) and in malignant lesions, particularly those ≥4 cm. FNAB was performed in 39.2% of the patients; there was no statistically significant association between FNAB performance and age group, sex, or pathology results. However, false-negative FNAB results were detected in 25% of malignant cases, indicating the limited sensitivity of FNAB, especially in nodules ≥4 cm.

Conclusion: Thyroid nodules measuring ≥4 cm may warrant surgical intervention regardless of whether FNAB was performed or reported as benign, due to their relatively higher rates of malignancy and associated complications.