Before surgery (first and second rows of images):

Clinical data: A 32-year-old woman requested an evaluation of a mass in the left side of the neck which was discovered by the patient several weeks ago.

Palpation: There was an elastic mass in the left submandibular area. The left had a not firm nodule.

Laboratory tests: TSH 2.37 mIU/L.

Ultrasonography. The thyroid was echonormal. The right lobe had small insignificant lesions. There were multiple nodules in the left lobe. The nodules were of different echogenicities. They included cystic lesion and a nodule with irregular borders. In some parts, the lesion showed bulging and the borders between the sternocleidomastoid muscle and the thyroid nodule were indeterminate. The palpable mass in the left submandibular area was a dominantly cystic lesion which had moderately hypoechoic solid part.

Cytology was performed form the nodular area in the left lobe and from the left submandibular mass. Total of six samples were taken. In neither case could cytology be assessed, there were only macrophages and blood elements on the smears.

Wash-out thyroglobulin of the left submandibular area resulted in 1047 microgram/L.

Final combined cytological-ultrasound-clinical diagnosis suspicion of papillary cancer metastasizing to the neck.

Total thyroidectomy was performed. Histopathology disclosed a T4b papillary cancer with gross extrathyroidal extension into the subcutaneous tissue. 11 out of 17 lymph nodes contained metastasis.

18 months after surgery (third row of images):

Clinical data: The patient received two courses of radioiodine therapy. Three months after the second session, the thyroglobulin was 4.3 microgram/L. Six month later the thyroglobulin rose to 11.7 microgram/L. The patient was referred for ultrasound examination.

Palpation: no abnormality.

Ultrasonography. There was no thyroid tissue in the thyroid beds. There were moderately hypoechoic lesions next to each other in the left side of the neck. The presentation corresponded to a conglomerate of metastatic lymph nodes.

Cytology resulted in papillary cancer.

The patient was reoperated and multiple lymph nodes were removed from the left side of the neck. Histopathology disclosed metastases of papillary cancer.

Comments.

1. It is not an unusual situation that we cannot gain adequate material from a cystic lesion. In this patient the clinical presentation was obvious and wash-out thyroglobulin justified the suspicion of thyroid cancer.

2. It is worth analyzing the presentation of the thyroid nodule regarding the presence of various suspicious ultrasound characteristics and that of the metastatic lymph nodes.