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For years now I have received thyroid ultrasound reports that give a good detailed description of large thyroid tumors within the gland, often describing presence or absence of micro-calcifications, vascular halos, irregular borders, and so on. Yet, these same reports ignore all of the other tumors within the gland that are considered to be sub-centimeter in size, as though these tumors are somehow exempt from being of any great significance.

As thyroidologists we are well aware of the small papillary cancers that are not infrequently found as an unrelated finding when performing thyroidectomy for some other indication. These are often within the 1-3mm size, and I am NOT referring to these little "incidentalomas".

The subcentimeter tumors I am talking about are often palpable tumors on examination and they may or may not be associated with other risk factors such as age, gender, worrisome physical characteristics, or the presence of Hashimoto's thyroiditis.

Below, I am including here three pathology reports from patients who had small palpable and suspicious thyroid tumors on physical examination. One had a positive FNA, the second had a false negative FNA, and the third did not have an FNA. All patients underwent total thyroidectomy with ipsilateral paratracheal lymph node dissection, considered by most thyroid surgeons to be the most minimally acceptable procedure for patients with significant papillary cancer. All had metastatic cancer.

The number of ipsilateral parathyroid lymph nodes a patient may have varies considerably. I recall seeing as many as 28, and as few as 0 on some pathology reports. Patients with Hashimoto's thyroiditis always have a large number of paratracheal lymph nodes.

Patient A had eleven paratracheal lymph nodes removed in her dissection and one had a small focus of metastatic cancer within it. Patient B not only had two out of three positive paratracheal lymph nodes in the lymph node dissection, but one perithyroidal lymph node found on the OPPOSITE side contained metastatic carcinoma, a contra-lateral metastasis, often considered a serious prognostic sign. Patient C had one positive node out of four.

All three patients had pre-operative ultrasounds that did not appear to be very excited about the patient's "subcentimeter" nodules, but they all turned out to have had significant cancers with worrisome regional metastatic disease.

What I am suggesting is that we should not ignore the significance and malignant potential of the so-called "subcentimeter" thyroid nodule on ultrasound. We ought to encourage the radiologists and our other ultrasonographers to take these nodules more seriously, describing them in detail, giving us as much information as possible about any suspicious physical characteristics.

The following are the three pathology reports discussed above: