A 42-year-old woman is found to have a thyroid nodule. Fine-needle aspiration cytology returns Bethesda Category IV (follicular neoplasm). Which is the MOST appropriate next step?

• A Repeat FNA in 6 months
• B Total thyroidectomy
• C Radioiodine thyroid scan to check for autonomous nodule
• D Diagnostic hemithyroidectomy (lobectomy) ✓

Explanation

Bethesda Category IV (follicular neoplasm/suspicious for follicular neoplasm) carries a 25–40% malignancy risk. Because cytology cannot distinguish follicular adenoma from follicular carcinoma (which requires capsular/vascular invasion on histology), diagnostic hemithyroidectomy (lobectomy) is recommended as the initial surgical procedure per 2015 ATA guidelines. Total thyroidectomy is performed if malignancy is confirmed histologically or if the patient has additional risk factors. Radioiodine scan is useful only if TSH is suppressed.

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

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Written and medically reviewed by the StethoPrep medical team.