The incidence of thyroid cancer has increased dramatically, yet the mortality has remained unchanged. There remain many challenges and "difficult problems" in diagnosing and treating patients with differentiated thyroid cancer (DTC). A significant percentage of patients with DTC will present with a thyroid nodule and an indeterminate fine needle aspiration biopsy underscoring the importance of proper evaluation and management. It is important when considering the extent of thyroidectomy and the management of lymph node metastases to balance the outcome of treatment in terms of recurrence and mortality with the morbidity of the procedure. Total thyroidectomy and lymphadenectomy for macroscopic lymph node metastases appear to be the optimal therapy for most patients with DTC. Preservation of function is a priority in managing patients with DTC invading the recurrent laryngeal nerve, trachea, esophagus, or the larynx.