A thyroid nodule with Bethesda category IV (follicular neoplasm/suspicious for follicular neoplasm) cytology on FNA: the most appropriate next step is:

• A Thyroid lobectomy with isthmusectomy ✓
• B Total thyroidectomy immediately
• C Repeat FNA in 6 months
• D Radioiodine uptake scan to look for hot nodule

Explanation

Bethesda IV cytology carries a malignancy risk of 25–40% and cannot distinguish follicular adenoma from follicular carcinoma on cytology alone (which requires histological demonstration of capsular/vascular invasion). Diagnostic hemithyroidectomy (lobectomy with isthmusectomy) is therefore the standard initial surgical approach, providing definitive histology. Total thyroidectomy is only recommended upfront if the contralateral lobe has suspicious nodules, or if the patient prefers. Repeat FNA will not resolve the diagnostic uncertainty, and a hot nodule on scintigraphy would effectively rule out malignancy.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.