A 35-year-old woman presents with a thyroid nodule. FNA cytology is reported as Bethesda Category IV (follicular neoplasm/suspicious for follicular neoplasm). What is the recommended next step?

• A Diagnostic hemithyroidectomy (lobectomy) to provide histological diagnosis ✓
• B Total thyroidectomy immediately
• C Surveillance with repeat ultrasound in 6 months
• D Repeat FNA to confirm diagnosis

Explanation

Bethesda Category IV (Follicular Neoplasm or Suspicious for Follicular Neoplasm) carries a malignancy risk of approximately 25-30%. FNA cannot distinguish follicular adenoma from follicular carcinoma because the diagnosis requires histological demonstration of capsular or vascular invasion, which requires examination of the entire specimen. Therefore, the recommended management is diagnostic hemithyroidectomy (lobectomy) to obtain tissue for definitive histology. If histology confirms follicular carcinoma, completion thyroidectomy may be performed based on risk stratification (size, invasion extent, vascular invasion).

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

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Written and medically reviewed by the StethoPrep medical team.