Can a patient request partial thyroid removal instead of Fine Needle Aspiration (FNA)?

Can a Patient Request Partial Thyroid Removal Instead of FNA?

No, a patient should not bypass FNA in favor of proceeding directly to partial thyroid removal, as FNA is the gold standard diagnostic test that determines whether surgery is even necessary and guides the appropriate extent of surgery if malignancy is confirmed. 1, 2

Why FNA Must Precede Surgical Decision-Making

FNA is the most accurate and cost-effective method for distinguishing benign from malignant thyroid nodules, with diagnostic accuracy approaching 95%. 1, 2 The fundamental problem with skipping FNA is that:

• The vast majority of thyroid nodules are benign - only 5% harbor malignancy, meaning most patients requesting surgery would undergo unnecessary operations 3
• Risk stratification cannot occur without tissue diagnosis - the American Thyroid Association's low-, intermediate-, and high-risk classification system requires postoperative histological features and cannot be applied before surgery 4
• Cancer subtype cannot be reliably determined preoperatively - while papillary thyroid carcinoma is well-detected on FNA, follicular carcinoma remains cytologically indeterminate, and medullary carcinoma is diagnosed or suspected in only 50% of cases based on cytology alone 4

The Clinical Rationale Against Diagnostic Surgery

Before widespread FNA use, only 14% of resected thyroid nodules were malignant; with current FNA protocols, over 50% of resected nodules are malignant - demonstrating that FNA prevents massive overtreatment. 3

The evidence shows that:

• FNA has reduced unnecessary thyroidectomies substantially by allowing accurate selection of patients who truly need surgery 2, 5
• Surgical excision without FNA exposes patients to permanent thyroid hormone replacement, surgical complications, and potential parathyroid/recurrent laryngeal nerve injury for what is statistically likely a benign nodule 5
• Even when FNA results are indeterminate (Bethesda III-IV categories), molecular testing can further refine risk before proceeding to surgery 1

When Surgery Without FNA Might Be Considered

The only scenarios where proceeding directly to surgery could be justified are:

• Compressive symptoms clearly attributable to the nodule (dysphagia, dyspnea, voice changes) where the nodule requires removal regardless of cytology 1
• Patient refusal of surgery despite confirmed malignancy on FNA - in highly selected cases of classical variant papillary thyroid microcarcinoma (PTMC) assessed as "low-risk," thermal ablation or active surveillance may be considered as alternatives, but this still requires FNA confirmation first 4
• Contraindications to surgery in confirmed low-risk PTMC, where alternatives to surgery exist 4

The Paradox of Current Guidelines

Recent guidelines acknowledge a significant clinical dilemma: for small nodules (<1 cm) classified as high-risk by TIRADS, FNA may not be recommended, yet nonsurgical options like thermal ablation require confirmed malignancy before treatment. 4 This creates an impossible situation where:

• Patients cannot be staged without surgery 4
• Risk stratification requires postoperative histology 4
• Alternative treatments require preoperative cancer confirmation 4

However, this paradox applies primarily to small nodules where observation is often appropriate, not to nodules requiring intervention.

Practical Algorithm for Patient Requesting Surgery Over FNA

1. Perform ultrasound-guided FNA first for any nodule >1 cm or <1 cm with suspicious features 1
2. If FNA shows Bethesda II (benign): Surveillance only unless compressive symptoms present 1
3. If FNA shows Bethesda III-IV (indeterminate): Consider molecular testing before surgery 1
4. If FNA shows Bethesda V-VI (suspicious/malignant): Proceed to appropriate surgery (extent determined by cytology and clinical factors) 1
5. If FNA is nondiagnostic: Repeat FNA under ultrasound guidance or consider core needle biopsy 1, 6

Critical Pitfalls to Avoid

• Do not perform diagnostic thyroidectomy without attempting FNA first - this represents overtreatment in the majority of cases 5
• Do not rely on ultrasound features alone - even highly suspicious sonographic patterns require cytological confirmation, as many benign nodules can appear worrisome 1
• Do not accept patient preference for surgery as sufficient indication - informed consent requires explaining that FNA will likely show benign disease and prevent unnecessary surgery 3, 5
• Recognize that "partial thyroidectomy" (lobectomy) still carries surgical risks including permanent hypothyroidism in 15-30% of cases, making FNA-guided decision-making essential 7

The standard of care requires FNA before any surgical intervention for thyroid nodules, with rare exceptions limited to cases where surgery is needed for compressive symptoms regardless of cytology. 1, 2, 7