Clinical presentation: A 62-year-old woman was referred for evaluation of a multinodular goiter detected on screening.

Palpation: The left lobe was nodular on palpation.

Functional state: euthyroidism (TSH 2.31 mIU/L).

Ultrasonography. The thyroid was echonormal. Beside small hypoechogenic discrete areas there was one hypoechogenic nodule in the right, while two moderately hypoechogenic lesions in the left lobe. The nodule in the upper third of the left lobe was suspicious on ultrasound because of the presence of microcalcifications.

Cytology was performed from the nodule in the upper part of the left lobe and resulted in papillary carcinoma.

Histopathology disclosed three different entities corresponding to the three nodules found on ultrasound: the right lesion proved to be a hyperplastic nodule, the upper left nodule a classic variant of papillary carcinoma while the lower left lesion did a microfollicular adenoma. Another focus of papillary carcinoma was found in the right lobe with a maximal diameter of 1.5 mm, which was a dominantly follicular variant of papillary carcinoma.

Comments.

1. The nodule in the lower pole of the left lobe has lobulated/spiculated margins.

2. Both the malignant nodule and the oxyphilic adenoma present all three possible signs which might suggest extrathyroidal extension: abutment, bulging and discontinuation of the thyroid capsule. The malignant tumor spread into the capsule but did not break it.