Clinical presentation: An 82-year-old woman was referred for evaluation of a thyroid nodule which was detected on physical examination. The patient told that us he noticed first this lump in the left side of the neck 5 months ago. Otherwise, she had no complaints.

Palpation: There was a firm nodule in the left lobe.

Functional state: euthyroidism with TSH 1.72 mIU/L.

Ultrasonography. The thyroid was echonormal. There was a large cystic nodule in the upper pole of the left lobe. The lesion presented relatively large hyperechogenic granules. There were multiple enlarged lymph nodes lateral to the left lobe, two of largest were cystic.

US-guided aspiration was performed from the nodule. Cytology resulted in papillary carcinoma.

Total thyroidectomy was performed. Histopathology disclosed papillary carcinoma in the left lobe metastasizing to the lymph nodes.

Comment.

1. Both the primary tumor and the solid part of the metastatic lymph node present lobulated margins.

2. It is doubtful whether the malignant nodule was a dominantly solid or dominantly cystic lesion because the acoustic shadow hinders the judgement of a significant portion of the nodule.

3. The cystic degeneration of a lymph node is itself suspicious of metastasis.