Is thyroidectomy medically necessary for a patient with a large nodule on the right and 2 smaller nodules on the left, palpable nodule on the right, and no signs or symptoms, diagnosed with non-toxic multinodular goiter and benign neoplasm of the thyroid gland?

Is Thyroidectomy Medically Necessary for This Patient?

Based on the clinical presentation described, thyroidectomy is NOT medically necessary at this time, as the patient lacks the key indications that would justify surgery: there is no evidence of malignancy, no compressive symptoms (dysphagia, dyspnea, choking), no growth documentation, and no suspicious imaging features requiring intervention. 1, 2

Critical Missing Elements That Would Justify Surgery

The patient's case lacks all of the established surgical indications for non-toxic multinodular goiter:

• No malignancy confirmed: The diagnosis states "benign neoplasm of thyroid gland," which by definition does not require surgical intervention unless other compelling factors exist 1, 2

• No compressive symptoms documented: The clinical information notes "no signs, symptoms" - patients requiring surgery typically present with dysphagia, dyspnea, choking sensation, or airway obstruction from large goiters 1, 3

• No documented nodule growth: The insurance criteria specifically require growth of 2mm or more within 1 year with 50% volume increase or 20% increase in two dimensions - none of this is documented 2

• No suspicious imaging features: While substernal extension is noted, this alone without compressive symptoms does not mandate surgery 1

What Should Have Been Done Instead

The appropriate management pathway that was bypassed:

• TSH measurement is mandatory first: All patients with multinodular goiter require serum TSH measurement to assess functional status before any treatment decisions 1, 2, 3

• Ultrasound-guided FNA biopsy should have been performed: For a large palpable nodule with smaller nodules present, fine-needle aspiration is indicated to definitively rule out malignancy, particularly for nodules >1-2 cm 4, 5, 1

• Risk stratification using TI-RADS scoring: The ultrasound should have included EU-TIRADS or ACR TI-RADS classification to quantify malignancy risk - nodules classified as TI-RADS 4 or 5 require biopsy 6, 4, 2

• Documentation of specific sonographic features: The presence or absence of microcalcifications, irregular margins, marked hypoechogenicity, and vascularity patterns should have been documented, as these determine biopsy indications 4, 5

Established Indications for Thyroidectomy in Non-Toxic Multinodular Goiter

Surgery is indicated only when one or more of the following are present:

• Confirmed malignancy on cytology: Nodules with malignant or suspicious cytology require surgical referral 1, 2

• Compressive symptoms: Dysphagia, choking, airway obstruction, or significant cosmetic concerns that impact quality of life 1, 3

• Documented growth with concerning features: Progressive enlargement with suspicious ultrasound characteristics 2

• Indeterminate cytology with high-risk features: Bethesda III-IV nodules that cannot be confirmed as benign may warrant surgery, though molecular testing can help refine this decision 4, 1

Critical Pitfall in This Case

The most concerning issue is proceeding to surgery without cytological confirmation of the nodule's nature. Even with a diagnosis stating "benign neoplasm," this should be based on FNA results, not clinical impression alone 5, 1. The risk of malignancy in multinodular goiter is approximately 5-10%, and a palpable nodule in this setting warrants tissue diagnosis before any surgical decision 5, 1, 3

Recommended Management Algorithm

For asymptomatic non-toxic multinodular goiter, the evidence-based approach is:

1. Measure serum TSH to confirm euthyroid status 1, 2, 3

2. Perform high-resolution thyroid ultrasound with TI-RADS classification of all nodules 4, 5, 2

3. Ultrasound-guided FNA biopsy of the dominant/largest nodule and any nodule with suspicious features (≥1 cm for TI-RADS 4-5, ≥1.5 cm for TI-RADS 3) 6, 4, 2

4. If cytology is benign (Bethesda II): Observation with periodic follow-up ultrasound at 1 year, 3 years, then every 5 years 4, 2

5. Surgery is reserved for: Malignant/suspicious cytology, symptomatic compression, or documented progressive growth with concerning features 1, 2, 3

Special Consideration: Substernal Extension

While substernal extension is noted in this case, this finding alone does not mandate surgery in the absence of compressive symptoms 1. However, if respiratory symptoms develop (orthopnea, positional dyspnea), then cross-sectional imaging with CT (without iodinated contrast if possible) would be indicated to assess tracheal compression, and surgery would become necessary 3

Risk of Proceeding Without Proper Workup

Performing thyroidectomy without FNA confirmation carries significant risks:

• Unnecessary surgery for benign disease: Most multinodular goiters are benign and can be safely observed 5, 1, 3

• Surgical complications: Risk of recurrent laryngeal nerve injury (1-10% temporary, up to 4% permanent), hypoparathyroidism, need for lifelong thyroid hormone replacement 7

• Missed opportunity for less invasive management: Asymptomatic benign nodules can be monitored, and emerging thermal ablation techniques may offer alternatives for symptomatic benign nodules 7, 2