A 28-year-old woman has a 2.3 cm thyroid nodule on ultrasound. Fine needle aspiration (FNA) cytology is reported as Bethesda category IV (follicular neoplasm). Molecular testing with Afirma Gene Sequencing Classifier returns 'suspicious.' What is the MOST appropriate next step?

• A Repeat FNA in 3 months
• B Radioiodine ablation
• C Diagnostic hemithyroidectomy ✓
• D Total thyroidectomy without further evaluation

Explanation

Bethesda IV cytology (follicular neoplasm) carries 25–40% risk of malignancy; an 'Afirma suspicious' result further increases this risk to approximately 50%. ATA 2015 guidelines recommend diagnostic hemithyroidectomy (lobectomy) as the initial surgical procedure, allowing histopathological diagnosis of capsular and vascular invasion which FNA cannot assess. Total thyroidectomy upfront without histology is inappropriate as ~60% of follicular neoplasms are benign adenomas; radioiodine has no role preoperatively.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.