Six years prior to present examination for 6 years (first and second rows of images)

Clinical data: A 60-year-old woman was referred for evaluation of nodular goiter. On evaluation of progressive difficulties in swallowing, palsy of the left recurrent nerve and a nodular goiter was discovered.

Palpation: The left thyroid was very firm. There very enlarged lymph nodes along the left carotid artery.

Functional state: euthyroidism with TSH 3.42 mIU/L.

Ultrasonography. The thyroid was echonormal. There was a deeply hypoechogenic nodule in the upper part of the left lobe while a moderately hypoechoic one in the lower two-third of the left thyroid. The former had irregular borders and presented necrotic areas. There were several enlarged lymph nodes in the left side of the neck.

Cytology of the hypoechogenic nodule and one of the lymph nodes resulted in papillary carcinoma.

Histopathology disclosed a T4 stage papillary carcinoma infiltrating the capsule of the organ. 7 of the 22 removed lymph nodes contained metastatic focus.

Present examination (third and fourth rows of images)

Clinical data: The patient underwent total thyroidectomy and radio-iodine therapy and thereafter she was managed in another hospital. The thyroglobulin level was between 2.9 and 5.5 ug/L in the previous years without any tendency. On the last visit a rise in the thyroglobulin level was detected (10.2 ug/L).

Palpation: a firm mass in the left thyroid bed.

Functional state: mild hyperthyroidism on daily 150 microgram levothyroxine with TSH 0.03 mIU/L, FT4 28.2 pM/L.

Ultrasonography. The palpable mass consisted of several hypoechogenic discrete lesions presenting microcalcification and irregular borders.

Cytology of the nodule resulted in papillary carcinoma.

Histopathology disclosed a T4 papillary carcinoma.

Comments.

1. The tumor contour was abutting and bulging at the first examination.

2. The usual signs of extrathyroidal spread are not defined in the event of an operated lobe because we cannot relate the nodule to the normal borders of the thyroid. Nonetheless, the tumor was located in the immediate vicinity of the strap muscle.