A 30-year-old woman has a Bethesda Category IV thyroid nodule (follicular neoplasm) on FNA cytology. Molecular testing using the Afirma Gene Sequence Classifier (GSC) shows a 'suspicious' result. Next management is:

• A Repeat FNA in 3 months
• B Total thyroidectomy immediately
• C Thyroid lobectomy (diagnostic hemithyroidectomy) ✓
• D RAI scan to differentiate hot vs cold nodule

Explanation

Bethesda Category IV (follicular neoplasm/Hürthle cell neoplasm) has a 25–40% malignancy risk and cannot be classified as benign or malignant by FNA cytology alone. The standard approach is diagnostic thyroid lobectomy (hemithyroidectomy), which allows permanent histology to differentiate benign follicular adenoma from follicular carcinoma (the latter diagnosed only by demonstrating capsular or vascular invasion). An Afirma GSC 'suspicious' result further supports proceeding to surgery. Total thyroidectomy at this stage is excessive without confirmation of 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.