Papillary Thyroid Cancer: Active Surveillance May Be the Best Choice

Female doctor examining woman’s thyroid area (throat).

Most small thyroid cancers are not threatening and don’t require immediate surgery.

Advances in cancer detection have saved many lives, but they have a serious drawback: Some cancers are being overdiagnosed. This leads to unnecessary treatment of tumors that never would have posed a threat if left alone.

For example, the reported rate of thyroid cancer in the United States has more than doubled since 1994, as scans have increasingly found tiny tumors that would have escaped notice in the past. Despite this surge in detection and treatment, the death rate for thyroid cancer has not budged — an indication that these tumors were not life threatening.

A new program at Memorial Sloan Kettering gives some people with very early-stage thyroid cancer the option of avoiding immediate surgery and instead having their tumor followed closely. MSK endocrinologist Michael Tuttle discusses thyroid cancer overdiagnosis and explains why the watch-and-wait approach is often the best choice.

What’s changed in the medical field that’s led to thyroid cancer now being overdiagnosed?

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Learn why thyroid cancer is being overdiagnosed.
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The main reason is that our technology got ahead of us. When I was a medical fellow in the early 1990s, the only thyroid cancers likely to be diagnosed were lumps I could feel with my hands. But around that time, ultrasound evaluations became available for use in routine clinical practice and identified many more small thyroid nodules than we could ever detect by touch. In addition, many CT and MRI images that happen to show the thyroid area were done for unrelated reasons — and often revealed tiny nodules.

When doctors see these nodules they often feel they must investigate further. With the help of ultrasound, it was increasingly easy to use a small needle to biopsy tiny nodules. Pathologists also started examining thyroid surgical samples much more closely, often finding very small specks of thyroid cancer even when the thyroid was taken out for an unrelated cause such as goiters.

I picture it like an iceberg. We used to see only what was floating above the water, but as we use more sensitive tests, we identify more cases below the water line. In fact, there have been multiple studies, some conducted by [MSK surgical oncologist] Luc Morris, showing how nonmedical factors contribute to this trend — for example, diagnosis rates are higher in counties with higher levels of income and more access to healthcare.

We now know that as much as 10 percent of the adult population has a small, subclinical thyroid cancer — meaning that it doesn’t cause symptoms — which comes to millions of cases in the United States. Currently, we’re diagnosing 60,000 cases a year, which is twice as many as two decades ago, but still only a fraction of the potential cases in the US population.

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Why is this increase in diagnosis a potential problem for patients?

It has become clear that most of these very small thyroid cancers never pose a threat. The most common type, papillary thyroid cancer, grows very slowly. They are the same size in someone at age 80 that they were at age 40.

Most of these very small thyroid cancers never pose a threat.
Michael Tuttle endocrinologist

But when someone has cancer, they or their doctor often want it out, and all surgeries carry some risk. Here at MSK, the complication rate is small, because our surgeons are very experienced. Nationwide, however, about half of thyroid cancer removals are done by surgeons who perform fewer than ten a year. In a small percentage of patients, surgery can damage the nerve that controls the vocal cords or the glands that regulate calcium in the bloodstream. In addition, patients whose thyroid is removed have to take hormones the rest of their lives. While most do fine, about 10 to 20 percent tell me they don’t feel good on the thyroid pills. They feel fatigued and have to press harder to function at their normal level.

So when you’re looking at a slow-growing cancer that’s not likely to be fatal, it is very important to question whether immediate surgery is required, especially if it could harm quality of life.

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How does MSK follow this approach of watchful waiting?

We have begun a tactic of active surveillance — a method pioneered very successfully at MSK with low-risk prostate cancer, another slow-growing type that historically has been overtreated. When someone comes in with a small papillary thyroid cancer that appears to be confined to the thyroid gland, we now try to determine whether he or she is a good candidate for observation.

If our thyroid cancer team feels that immediate surgery is not required, we offer the chance to have an ultrasound every six months for two years, when we will look closely at the site of the cancer and the nearby lymph nodes to see if there is any change. After two years, we start spacing out the ultrasounds, to every nine or 12 months.

We know that in the vast majority of cases, if thyroid cancer progresses, it’s going to happen very slowly — in which case our surgical treatments will almost certainly be as effective in the future as they would be now. There is a small chance we will identify spread of cancer cells to lymph nodes around the thyroid at some point. But the chance of this is actually the same whether we do active surveillance or take out the thyroid up front.

I tell my patients that it’s OK if I’m wrong in the short term — we can do surgery later and be just as effective.

Some small tumors are not appropriate for this method, depending on location and other factors, but those are a tiny group. We’ve been following more than 225 patients for a median period of about two years. Out of those patients, only about four or five have tumors that have grown.

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How have patients reacted to this option? Is there any reluctance to leave cancer untreated?

Some patients do want surgery right away. But a surprising number are interested in avoiding the operation. Many don’t want to be on pills, or they’ve had family members or friends who have had thyroid surgery and don’t feel well. I find that a lot of people choose observation as a bridge to postpone treatment — they’ve just gotten a new job, or something else is going on, and they don’t want surgery now if it’s not essential. I remind them that they can always change their minds at any time, and that I may change my mind if I see something I don’t like.

I remind [patients] that they can always change their minds at any time.
Michael Tuttle Chief, Endocrinology Service

Of course, when you’re seeing an individual patient, it is impossible to know if his or her thyroid cancer will be stable for years under observation or if it will grow over the next year or two.

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Is there a way to get a better idea of which tumors will actually grow?

This is a very important question we are actively researching. The laboratories of [MSK physician-scientist] James Fagin and [MSK genomics researcher] Michael Berger are actively doing research to try to determine whether there is a genetic signature that would allow us to predict what’s going to happen. If we can identify which mutations are important, we could just use a small needle to biopsy the cancer, analyze the genes, and be able to more accurately predict the likelihood that an individual cancer will progress.

I think patients would find that kind of information very helpful in deciding whether to be watched or proceed to immediate surgery. So even though active surveillance is working well in the vast majority of our patients with very small papillary thyroid cancers, we’re trying to use our molecular research laboratories to give us an even clearer idea of which tumors will cause problems so we can give our patients the best option.

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If I have a nodule .74cm x .77cm x .8 cm that affirma veracyte diagnosis came back suspicious for malignancy bethesda category V and my BRAF came back Positive (last May 2015) but previous to that had been monitoring for 5 years with no growth as the previous biopsy was inconclusive but ultrasounds shows irregular margins and micro-calcifications should I continue to do active surveillance or are these BRAF test accurate in proving these papillary micro -carcinomas as aggressive and have surgery immediately ? I read somewhere these BRAF tests are not that accurate? I guess I am mainly concerned on how accurate the BRAF tests are?

Dana, thank you for reaching out. We suggest you speak with your physician about your individual case and your options, as this is a complex topic that is affected by a large number of factors.

Is it true that papillary cancerous nodules in the thyroids of older people (over 74) are prone to quicker growth? Is a single small nodule of 1 cm, still suitable for active surveillance? If people wait, growing older, wouldn’t surgery be possibly more complicated due to their advanced age?

Thank you for reaching out. We suggest you consult with your personal physician on these questions, as every individual case is different and a large number of factors (including age) play a role in treatment decisions.

The information at this link may be of interest to you:…

For other questions about thyroid cancer treatment, you also can call the National Cancer Institute’s Cancer Information Service at 800­4CANCER (800­422­6237). To learn more about the CIS, including Live Chat help and how to send them an email message, go to

I have a question about one paragraph in your description that reads: "We know that in the vast majority of cases, if thyroid cancer progresses, it’s going to happen very slowly — in which case our surgical treatments will almost certainly be as effective in the future as they would be now. There is a small chance we will identify spread of cancer cells to lymph nodes around the thyroid at some point. But the chance of this is actually the same whether we do active surveillance or take out the thyroid up front."

A. Specifically, I was not able to find references in the medical literature that confirm the part about - "our surgical treatments will almost certainly be as effective in the future as they would be now". Could you quote those medical papers and post it on the website? I try to read as much as possible in the medical literature before making my decision. I am sure that others would also appreciate it.

B. Writing about lymph node spread to the neck it stated that "our surgical treatments will almost certainly be as effective in the future as they would be now". Again, I looked very hard to find anything about this and could not. Would you be so kind and post the citations for the papers that confirm this notion? I would be looking for a study where half the patients are signed up to have surgery right away and another half some years in the future, showing that their surgeries reveal the same number of lymph nodes with cancer and their complications from surgery and/or cancer were the same.

Thank you very much for posting this helpful information on public web site. I am looking forward to your reply! Arik (medical student)

Arik, thank you for your comment. We consulted with Dr. Tuttle, who responds:

This is a very good question. The best data we have comes from the Kuma Clinic series in Japan that shows that excellent clinical outcomes are seen with either immediate surgery or an observational management approach:

Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery.
Oda H, Miyauchi A, Ito Y, Yoshioka K, Nakayama A, Sasai H, Masuoka H, Yabuta T, Fukushima M, Higashiyama T, Kihara M, Kobayashi K, Miya A.
Thyroid. 2016 Jan;26(1):150-5. doi: 10.1089/thy.2015.0313. Epub 2015 Nov 5.

I was recently diagnosed with papillary thyroid cancer. My 30 year old daughter and sister who at 51 was diagnosed with the same. Are there any family studies going on currently?

Linda, thank you for your question. At Memorial Sloan Kettering, families with 3 or more first-degree relatives with thyroid cancer are usually referred to our Clinical Genetics Service:…

They can provide the most up-to-date information regarding hereditary cancer syndromes.

In addition, there is a registry of familial non-medullary thyroid cancer at the National Institutes of Health being run by Dr Electron Kebebew:

Hi I had a unrelated scan and it came back thyroid nodules. Mostly small one dominate at 1.5 1.7 1.8
FNA came back suspecious of Papillary Cancer with Braf negative
My ENT says I should have complete thyroidectomy. He also is moving out of state in 2 months.
He said if I were an accountant it would be ok to wait till next May when business is slow.
I have already vitamin D defiency and B 12 I have kept diabetes under control with diet. A1c 6.3 I'm 58 and other than arthritis have no other elements. I fear the pill for life wil become a life long battle effecting many other issues. Can I just observe

Dear Sherri, we cannot offer recommendations regarding the next steps in your care without a full examination and knowing more about your medical history and pathology. If you would like to make an appointment with one of our specialists for a second opinion, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Hi, I had PTC in a single nodule of 5mm and had a total thyroidectomy. In the surgery, the doctor was surprised to discover that it had spread to a lymph node (central compartment) because the nodule usually gets larger before it starts spreading. I am not asking for any specific advice as I have already completed my treatment. But my question is; do you think lymph metastasis on such a small nodule is strange and could be a sign of more aggressive tumor? My second question is whether research shows that papillary carcinomas with lymph metastasis have a higher likelihood of recurrence after treatment than those confined to the nodule.
Thank you

Steve, thank you for your question. We consulted with Dr. Tuttle, who responds: “Multiple previous studies have demonstrated that very small thyroid cancers very frequently spread to lymph nodes immediately around the thyroid. But in the majority of cases, the abnormal lymph nodes remain very small and do not become clinically apparent. As a result, we don’t consider the finding of very small lymph node metastases to be a sign of aggressive behavior of the thyroid cancer. However, the risk of recurrence is higher in patients that have multiple metastatic large lymph nodes.”

Thank you for your response. As you mentioned that the abnormal lymph nodes in such cases often remain very small and not clinically apparent. So how would one be able to find them in such cases? I know there are many schools of thought that do not recommend a complete neck dissection for such microcarcinomas. So a patient could be declared cancer free but still harbour traces of metastasis in the lymph nodes for years to come without anyone's knowledge. So what is considered good practice to avoid such situations? (I presume ultrasound and RAI body scan may not always be accurate enough to detect these).
A second question; what level of thyroglobulin antibody would be considered high enough to interfere with the thyroglobulin readings to monitor for recurrence?

Steve, we followed up with Dr. Tuttle, and he replied:

In most cases, the small abnormal lymph nodes are never identified. As long as they remain too small to be seen on ultrasound, they cause no problems. But is correct to assume that many patients have very small volume lymph node metastases in the neck from papillary thyroid cancer that they are unaware of and fortunately cause no problems in the future.

Any level of thyroglobulin antibody can interfere with the serum thyroglobulin readings.

My daughter age 32 has been diagnosed with papillary carcinoma after imaging and followed by fine needle biopsy. The thyroid node is 1.1 cm and has apparantly grown from .9 cm from a previous ultasound 4 years ago. In the biopsy they also found a lymph gland below the thyroid that was positive for cancer. It is apparantly quite near to the carotid artery. She has been in consultation with two surgeons, who both recommend surgical removal of the thyroid and lymph gland and afterwards RAI treatment. My question is whether in the situation described above you would recommend active surveillance? She is in a bit of a dilemma presently as the two surgeons had slightly different approaches to more agressive than the other, and hasnt made a decision yet and was wondering about this other option of active surveillance?
Thank you

Dear Sharon, we are sorry to hear about your daughter’s diagnosis. If she would like to speak with one of our specialists about possible next steps in her care, please ask her to call our Physician Referral Service at 800-525-2225. They can make an for a consultation to discuss potential treatment options, including whether she would be an appropriate candidate for active surveillance. Thank you for reaching out to us.

Can you explain the cutoff age of 45 in the staging of ptc. Why 45?I have been reading that the cutoff might change soon, is this true? thank you.

Catarina, thank you for your question. We asked MSK endocrinologist Michael Tuttle for clarification on the age cutoff, and he responds:

“Traditionally, the AJCC/TNM risk stratification system that is used to predict the risk of dying from differentiated thyroid cancer has used an age cutoff of 45 years old at the time of diagnosis as one of the key features for staging of thyroid cancer. However, in the most recent version of the AJCC/TNM risk stratification system published in October 2016, the 8th addition, that age cutoff has been increased to 55 years of age. Patients less than 55 years of age are grouped into either stage one if there is no evidence of distant metastasis or stage II if distant metastasis are present. Patients older than 55 years of age are grouped into one of four stages based on the size of the tumor, lymph node involvement, tumor growth into surrounding major structures, and distant metastasis. The net effect of raising the cutoff to 55 years of age means that more patients are appropriately classified as low risk than in the previous staging systems.”

Three different qualified pathologists have looked at my post-thyroidectomy slides. The first diagnosis was papillary thyroid carcinoma, classical variant (usual). The second diagnosis was papillary thyroid carcinoma, classic type with tall cell features. The third and most recent diagnosis is papillary thyroid carcinoma, Warthin-like variant with peripheral change to tall-cell variant papillary carcinoma (approximately 20% of total tumor mass). I think that the last diagnosis is accurate, but how do you know which one is correct? Why can't I get a definitive diagnosis from the pathologists?

My husband has his thyroid removed and another tumor grew enclosing his carotid artery which Dr. Shaha removed. Now after weeks of radioactive therapy, the papillary cells in his lymph nodes and lungs remain. What Now??

Dear Margaret, we are sorry to hear about your husband’s diagnosis. We recommend that you talk to his oncologist to discuss appropriate next steps in his care plan. Thank you for reaching out to us.

I understand the University of Pittsburgh has been conducting some research to identify antigens associated with cancer in the thyroid. I am wondering if examination of biopsies for those type of antigens would be beneficial in generally diagnosing whether it is better to watch and wait or to have thyroid surgery to remove the growth.

Margaret, thank you for reaching out. The research on antigens that you mentioned is still too new to determine its usefulness in making treatment decisions. Every individual case is affected by a large number of factors. If you are interested in learning about treatment of thyroid cancer at Memorial Sloan Kettering you can read more here:

Is staging of Papillary Thyroid Ca based on Isthmus tumor size (3 cm) or largest size of lymph node metastatic focus (4.2 cm) ? 10/18 lymph nodes positive at central neck, total thyroidectomy Question from 45 year old male with pT2N1a Pathology staging

Bill, thank you for reaching out. When staging thyroid cancer, the tumor size (T classification) is based on the size of the largest thyroid cancer nodule in the thyroid. The size of lymph node metastases are not used in the staging system.

I was diagnosed with a solid solitary nodule on one of my thyroid lobes. It was 5mm two years ago when it was first discovered by a non-related ultrasound of my neck. Now two years later it has increased in size to 1cm.
I was done a FNA biopsy and it came inconclusive, with a 60% chance. I have no family history of thyroid cancer or any symptom at all. My doctor nonetheless recommended removal of one of the lobes.

Per your observation method, do you generally recommend observation for this kind of nodule and after an inconclusive biopsy?

Carlos, thank you for reaching out. Unfortnately we cannot speak to specific medical questions without examination, as every individual case is different and affected by a large number of factors. If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to

Thank you for your comment.

I am so thankful that this sensible approach is being taken and that many people are being spared unnecessary surgery, lifelong complications without a thyroid, and the dramatic quality of life decrease that would ensue. Way to go! I hope that more research can be done to uncover the *cause* of thyroid cancer, whether it be hormonally-related, environmental toxins, chronic deficiency of iodine/selenium, or WHATEVER ELSE. I wish you all well as you uncover more in your research. (P.S. I have papillary thyroid cancer and am currently "watching and waiting." age 35, mother of 5....I need my thyroid!).

I have a 1 cm nodule (left lower, complex with cystic component, adenomatous with pseudopapillary hyperplasia). Thyroseq GC results came back with an intermediate/-40% cancer of cancer. Would I be a good candidate for observation, rather than removing half of my thyroid?

I am a 60 year old woman in good health and I have had one nodule on the right side of my thyroid since the birth of my daughter 23 years ago. I have had ultrasounds, FNAs, and about 17 years ago a radioiodine scan. All indications have been that the nodule is non-cancerous. The nodule has been quite large (5.9x3.5x2.9) from the beginning, changing shape only slightly and slowly over the years. I have no difficulty breathing or swallowing, etc., nor any hypo- or hyperthyroid symptoms, my thyroid hormone levels are in range and I feel fine. In the last 2 years, a few more small nodules have been detected and the FNAs on them have come out benign for those. More recently the FNA on the big nodule has be described as "indeterminate" and in one case "suspicious" and doctors have been urging me to have a total thyroidectomy. Because I feel fine and all previous FNAs have been benign, I can't see the point after all this time. Do benign nodules become cancerous (it was my understanding that they don't)? Do you have any resources you could guide me to? Thank you!

Dear Kristin, we’re sorry to hear you’re going through this. We can’t offer medical advice on our blog, but you may want to reach out to the National Cancer Institute’s Cancer Information Service at 800-4CANCER. They may be able to provide you with some helpful resources. Thank you for your comment, and best wishes to you.

Does age play a factor in considering the option of active surveillance for papillary thyroid cancer? My 17-year old son was diagnosed last week after an 8mm node was found in an ultrasound and biopsied. We are evaluating options and surgeons now so wanted to know if his young age would rule him out for this.

Polly, thank you for reaching out. We consulted with MSK endocrinologist Michael Tuttle, who responds:

“All of the studies done on observation have been in patients at least 18 yrs of age. As a result, surgery is usually recommended for thyroid cancers in patients younger than 18 yrs old.”

I was wondering if you have any experience with PTC in a patient that has Lynch Syndrome. I know that thyroid is not one of the usual Lynch cancers but my question is if you think the MMR gene defect would cause the cancer to grow faster in a Lynch patient than it would in a non-Lynch patient? In addition to that, does Hashimoto's play into the surgery vs surveillance
Thank you!

Sue, thank you for reaching out. We consulted with MSK endocrinologist Michael Tuttle, who responds:

We would not expect the clinical outcome of thyroid cancer that developed in the setting of Lynch disease to be significantly different from the same thyroid cancer developing in a patient without Lynch syndrome. Hashimoto’s often causes changes on the ultrasound throughout the thyroid gland that makes it more difficult to follow a patient with papillary microcarcinoma with observation since it is often hard to tell which changes on the ultrasound are related to thyroid cancer and which are related to the underlying inflammation of Hashimoto’s.

I would like to ask about my sister's Papillary Thyroid Cancer. Can she just have half of her thyroid gland removed now since the cancer is only in one side of her neck? (If the cancer comes back, she can have surgery again!)
This is what happened. My sister had not seen doctors for two years. Then she lost her full time job that she really loved. She felt very depressed and even talked about suicide! At the time she lost her job (2 years ago), she had very bad cough, two root canal teeth and five fillings needed. She was very forgetful; but she thought she had spring she used to have. She just went to dentists to treat her teeth but did not see any medical doctor. A year ago, she let me feel about 6 big lymph nodes on her right neck (0.5-4cm), She and I thought the lymph nodes got big because she got long infection in her mouth and would come back to normal size. However, they did not! Last month, she visited a doctor's office and had the nodes/thyroid biopsy and CT scan. Doctor found out she had Papillary Thyroid Cancer and recommended her for surgery (will refer to another office....). She was so scared and never talked to any one from the doctor's office! She asked me if I can find any good doctors that treat her cancer without the hormonal pills. She meant: please help treat her cancer without removing her entire thyroid gland.

Hi my name is April cox; I have a single nodule that was found during a pet scan. I had a ultrasound and a fna biopsy. The results were indeterminate. I saw a surgeon and he said he could do surgery. I met with a radiological doctor and she said we can watch it and ultrasound it in 6 months. My ct scan says it is stable. And my second pet scan shows the sugar intake was less. It is 1.5 cm. Am I doing the right thing to be observed. I went through surgery for colon cancer and had radiation for liver and lung and am tired of being treated

I had a total thyroidectomy after a 1.2 cm lesion on the outside surface of my thyroid was detected. After I received 100 mCi of RAI. Thyroglobulin is less than 0.2 if there is a recurrence what are the treatment guidelines for readministering RAI or surveillance? I am having trouble finding this information. Thank you.

My wife's papillary thyroid cancer nodule is 2.5 cm. Why is her or anyone else's nodule more of a health risk than a nodule smaller than 1 cm?

Dear Wayne, we’re sorry to hear about your wife’s diagnosis. If you would like to discuss this with an expert at MSK, the number to call for a consultation is 800-525-2225. You can go to for more information on scheduling an appointment.

If you are not looking to make an appointment but just looking for general information, we recommend that you reach out the the National Cancer Institute’s Cancer Information Service at 800-4CANCER. Thank you for your comment, and best wishes to both of you.

I was diagnosed with thyroid cancer, papillary carcinoma, 6 1/2 years ago. The doctors recommended to remove my thyroid and follow-up with RAI treatment. I had the surgery, but had to delay the RAI treatment a year as I was trying to get pregnant through IVF. Last year my thyroglobulin started creeping up and my doctor ordered an ultrasound. The ultrasound showed some minor concern, but we decided to simply monitor through blood work and check on it in 6 months. My thyroglobulin continued to creep up, so my doctor ordered a biopsy, which showed Stage 1 cancer. My doctor recommended RAI treatment, but unfortunately there was no uptake. We ran more blood work 5 months later and my thyroglobulin continued to increase to 2.5, at which time he referred me to an oncologist. I met with two oncologist, one at Jefferson Hospital in Philadelphia and another at Fox Chase also in Philadelphia. Both oncologist recommended surgery. I then met with 2 surgeons, the first agreed I need surgery while the second believes I might just need observation. Unfortunately, the second surgeon did not have all my medical records needed to make a full assessment and I am right now waiting to hear back from the second surgeon. I am wondering since I already had my thyroid removed, would I still be a candidate for continued observation? I already feel very fatigue throughout the day since my thyroid was removed, would removing 20-30 lymph nodes at this point make a difference?

Based on what I've read on your site ... if PTC nodule is in close proximity to an artery, active surveillance/watchful waiting is not ideal, correct? Also, is there a difference between active surveillance and watchful waiting. Thank you!

Dear Anne-Marie, the terms “watchful waiting” and “active surveillance” are often used in the same way. MSK prefers the term “active surveillance” because active, regular monitoring is part of the process.

Unfortunately, we are not able to answer questions about specific cases on our blog. If you’d like to consult with one of our experts, you can call 800-525-2225 or go to for more information on making an appointment. Thank you for your comment, and best wishes to you.

Can small thyroid nodules ( under 1 cm) spread to lymph nodes? I have had three enlarged lymph nodes for two years now and multiple small thyroid nodules. My doctor tell me to watch and wait. Is this a safe approach if lymph nodes are involved?