First examination (first row of images):

Clinical presentation: A 68-year-old woman was referred for evaluation of a nodular goiter discovered on routine physical examination.

Palpation: Both lobes had elastic nodule.

Results of blood test: TSH 4.21 mIU/L, FT4 11.9 pM/L, aTPO 481 U/mL.

Ultrasonography. The thyroid was moderately hypoechogenic. There were two central-type cysts, one in the left lobe and another one in the right lobe. Both had perinodular vascularization.

4 mL serous fluid was aspirated. Aspiration cytology resulted in benign cystic lesion.

Suggestion: yearly TSH-determination, ultrasound in three years.

Second examination 3 years later (second row of images):

Clinical presentation. The patient came to routine follow-up visit. She has lost her husband for three months and thereafter diffuse complaints including weight loss, anxiety and sleep disturbance had evolved.

Palpation: unchanged.

Result of blood test: TSH 5.61 mIU/L.

Ultrasonography. The right cystic nodule has in part refilled. Otherwise, the presentation remained unchanged.

Suggestion: TSH determination in 6 months, ultrasound in 3 to 5 years.

Comment.

1. This case illustrates how a spongiform type cyst might evolve from a central-type cystic nodule. See video and longitudinal scans of the right lobe.

2. The nodule has tiny hypoechoic areas, therefore the lesion can be regarded as an EU-TIRADS 4 lesion. Nevertheless, the hypoechoic areas do not raise the possibility that they would represent another pathological entity, therefore, is seems to be more accurate to classify the nodule as an EU-TIRADS 3 lesion.