First examination (first row of images):

Clinical data: A 61-year-old woman was referred for evaluation of a suspicious recurrent nodule which was discovered on carotid Doppler examination. The patient was operated on Graves' disease 17 years ago. Histopathology disclosed diffuse goiter.

Palpation: no abnormality.

Laboratory tests: TSH 3.09 mIU/L on daily 75 microgram levothyroxine.

Ultrasonography. There was a small, moderately hypoechoic remnant according to the resected right lobe while a much larger but still small remnant was found in the left thyroid bed. The latter had an amorphous discrete lesion which presented bright echogenic granules. The lesion was avascular.

FNA was performed from the mass. There were no follicular cells on the smear, only inflammatory cells were found. Our diagnosis was granulation around surgical thread.

Second examination (second row of images):

Clinical data: The patient came to a routine follow-up.

Palpation: no abnormality.

Laboratory tests: TSH 3.84 mIU/L on daily 75 microgram levothyroxine.

Ultrasonography. The presentation of the thyroid was essentially the same. The mass in question became smaller. This was avascular and proved to be hard on elastography.

Comments.

1. A surgical procedure has a great and permanent impact on the ultrasound pattern and results in discrete lesions on ultrasound. It is very unlikely that years after the surgery, true nodules will evolve in a patient who previously had a histopathologically proven non-nodular thyroid. The patient' history is of the greatest help in such cases to avoid overinterpretation of discrete lesions.

2. A granulation around surgical thread is always avascular. This is usually presented as an echonormal, irregularly shaped mass which has echogenic granules. It is always avascular and hard.