A 42-year-old woman is found to have a 3 cm right thyroid nodule on routine examination. Thyroid function tests are normal. Ultrasound shows a hypoechoic nodule with irregular margins and microcalcifications. Fine-needle aspiration cytology reports a Bethesda category V (suspicious for malignancy) result. What is the most appropriate next step?

• A Total thyroidectomy ✓
• B Right hemithyroidectomy (thyroid lobectomy) and await final histology
• C Repeat FNAC in 6 months
• D Radioactive iodine ablation without surgery

Explanation

A Bethesda V cytology (suspicious for malignancy) combined with high-risk ultrasonographic features (hypoechoic, irregular margins, microcalcifications) in a nodule over 1 cm strongly predicts papillary thyroid carcinoma; total thyroidectomy is the appropriate definitive surgery as it allows complete removal of bilateral disease, facilitates postoperative radioiodine therapy if needed, and simplifies surveillance with thyroglobulin. Hemithyroidectomy may be considered for low-risk Bethesda V nodules less than 4 cm without high-risk features, but the combination of size and sonographic findings here favours total thyroidectomy. Repeat FNAC is appropriate for lower Bethesda categories. Radioiodine cannot be used as primary treatment without prior surgical diagnosis.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.