Clinical presentation: A 39-yr-old hypothyroid woman came to follow-up examination. She has been diagnosed with a Bethesda III FNA, and a combined ultrasound-cytological report of suspicion of papillary cancer during the 13th gestational week of her pregnancy for 16 months. We suggested that until breastfeeding is completed, surgery can be delayed with certainty.

Palpation: no abnormality.

Laboratory test: TSH 2.03 mIU/L on daily 125 microgram levothyroxine.

Ultrasonography. The right lobe was composed of echonormal and hypoechoic fields. The echogenicity index was above 50%. There was not a discrete mass but an area presenting numerous not microcalcifications but punctate echogenic foci in the ventral part of the left lobe. There were isolated microcalcifications relatively far not from this lesion but from this part of the lobe.

Based on the ultrasound presentation, I suggested surgery. I thought at the time of the examination, that the punctate echogenic granules are unequivocal microcalcifications.

Histopathology disclosed Hashimoto's thyroiditis.

Comment.

1. This is a really deceptive pattern. I repeat myself, the clue is the realization that these echogenic granules are not within a discrete lesion. Theoretically, we cannot exclude the possibility that according to a papillary cancer there is no discrete lesion but it would be an extremely rare situation.

2. The presentation deceived me, the pattern was falsely interpreted as starry-sky phenomenon but indeed these punctate echogenic foci are very likely presentations of fragmented connective tissue.

3. Two years had to pass after the operation, when, after many examinations, I finally realized the real problem: there is actually no circumscribed lesion in the area where the punctate echogenic figures are found. I indicated this recognition by correcting some captions.

4. The interpretation of the echogenic figures has a deep impact on the judgement of nodule borders. If we falsely consider the echogenic spots as microcalcifications, than this case would be an example of invasive spread.