Clinical presentation: A 33-year-old woman requested a second opinion. She has been treated for hypothyroidism for several years, but ultrasound examination has not been performed, yet.

Palpation: Both lobes were very firm.

Functional state: euthyroidism on daily 112.5 microgram levothyroxine (TSH 2.91 mIU/L).

Ultrasonography. The thyroid was hypoechogenic. There was a lesion in the ventral part of the right lobe displaying a very unusual presentation: this was consisted of a central hypoechogenic area surrounded with an echonormal rim. The lesion presented microcalcifications and had an irregular border but did neither perinodular nor intranodular blood flow.

Cytology resulted in papillary carcinoma.

A total thyroidectomy was performed. Histopathology disclosed papillary carcinoma with a maximal diameter of 12 mm. Thereafter the patient was reoperated.

Comment. Although the evaluation protocol of hypothyroid patients does not necessarily include ultrasound, we regularly perform at first examination.