Clinical data: a 27-year-old woman was referred for evaluation of growing nodules. She was treated for hypothyroidism for 19 years. On the first ultrasound multiple echonormal and hyperechogenic nodules were described and the largest one was aspirated. The cytological diagnosis was suspicion of follicular carcinoma. A subtotal left lobectomy was performed when she was 10. Histopathology disclosed Hashimoto's thyroiditis without any nodules. On regular follow up the hyperechogenic nodules were found to increase in size, from 8 to 11 and from 12 to 16 mm over fifteen years.

Functional state: euthyroidism on daily 162.5 microgram levothyroxine (TSH 0.92 mIU/L).

Ultrasonography. Both thyroids were hypoechogenic and presented fibrosis. There were two echonormal lesions in the right thyroid, one in the central part and another one in the lower pole of the lobe. They were not of regular geometrical shape.

Comments.

1. The echonormal areas corresponded to only intact parts of the thyroid not or less influenced by the underlying thyroiditis. The growing of these parts of the thyroid is not a pathological phenomenon. Consider that a normal thyroid also increases from childhood to adult life. Moreover, similar echonormal areas were removed for 15 years and no nodules were found on histopathology.

2. Although we cannot step twice in the same river, occasionally one makes an attempt...

 

Unfortunately, the story did not end at this time. So, I had to extent the original case study.

 

On the follow-up visit three months later she informed us that an aspiration cytology was performed from the "nodule in the right lobe" in another institution which was suspicious of follicular carcinoma. We advised her against stepping in the same river twice and recommended regular follow-up instead of repeated surgery. She asked me to perform another aspiration biopsy.

Combined clinical-ultrasound-cytological diagnosis was Hashimoto's thyroiditis.

I tried to convince the patient to avoid surgery but I have failed.

Histopathology disclosed Hashimoto's thyroiditis. No nodule was found.