A 52-year-old woman from Delhi presents with a solitary thyroid nodule (2.5 cm) detected on routine ultrasound. Fine-needle aspiration cytology (FNAC) shows follicular neoplasm (Bethesda Category III). Thyroid function tests are normal. What is the most appropriate next step in management?

Question

Accepted Answer

D. Thyroid lobectomy with intraoperative frozen section. ## Clinical Context

A Bethesda Category III (atypia of undetermined significance / follicular neoplasm) result on FNAC carries a 15–30% risk of malignancy. The nodule is 2.5 cm (>2 cm), which increases suspicion. Repeat FNAC has poor sensitivity and delays diagnosis; observation alone is inappropriate given the size and cytology.

## Management Algorithm for Bethesda III Nodules

```mermaid
flowchart TD
  A[Bethesda III FNAC]:::outcome --> B{Nodule size?}:::decision
  B -->|< 1 cm| C[Observation + ultrasound]:::action
  B -->|1-2 cm| D[Consider molecular testing]:::action
  B -->|> 2 cm| E[Thyroid lobectomy + frozen section]:::action
  E --> F{Frozen section: malignancy?}:::decision
  F -->|Yes| G[Completion thyroidectomy + RAI]:::action
  F -->|No| H[Observe contralateral lobe]:::action
```

## Key Point:

**Thyroid lobectomy with intraoperative frozen section is the gold standard for Bethesda III nodules >2 cm.** This approach:
- Provides definitive histology (frozen section)
- Allows completion thyroidectomy if malignancy is confirmed
- Avoids unnecessary total thyroidectomy if benign
- Minimizes morbidity (single-stage surgery if benign)

## High-Yield:

**Bethesda Category III carries 15–30% malignancy risk.** Size >2 cm warrants surgical evaluation rather than repeat cytology or observation alone.

## Clinical Pearl:

Molecular testing (ThyroSeq, Afirma) can help refine risk in Bethesda III, but in a resource-limited setting or when unavailable, lobectomy with frozen section remains the standard of care in India.

![Thyroid Neoplasms diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/4156.webp)

Answer

A. Observation with ultrasound surveillance every 6 months

Answer

B. Total thyroidectomy followed by radioactive iodine ablation

Answer

C. Repeat FNAC in 3 months

A 52-year-old woman from Delhi presents with a solitary thyroid nodule (2.5 cm) detected on routine ultrasound. Fine-needle aspiration cytology (FNAC) shows follicular neoplasm (Bethesda Category III). Thyroid function tests are normal. What is the most appropriate next step in management?

Explanation

Clinical Context

Management Algorithm for Bethesda III Nodules

Key Point:

High-Yield:

Clinical Pearl:

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